Impulse Control Disorders

Disruptive, Impulse Control and Conduct Disorders

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Playfulness, curiosity, adventurousness, creativity, and even mischievousness are considered to be typical elements of human development and personality that are often viewed positively and encouraged as elements of a fulfilling life.

However, these same characteristics may present a challenge when they are disruptive, uncontrolled, and interfere with an individual’s ability to learn and comply with the “rules” of the culture, community, family, and all the related spaces that he or she occupies. When such characteristics lead to behaviors that are potentially harmful to individuals and/or those around them and interfere with daily function, these individuals may be diagnosed with disruptive, impulse-control, or conduct disorders.

This literature specifically addresses the disorders that reflect functional difficulty with self-control of emotions and behaviors that conflict with social norms or “conduct,” including disruptive, impulse-control, and conduct disorders—all of which fall under the category of disruptive behavior disorder. These conditions include: oppositional defiant disorder (ODD)Opens in new window, intermittent explosive disorderOpens in new window, conduct disorderOpens in new window, antisocial personality disorderOpens in new window, pyromaniaOpens in new window, and kleptomaniaOpens in new window.

These disorders are manifested by behaviors that violate the rights of others through aggression or property destruction that bring the individual into significant conflict with societal norms and/or authority figures.

The underlying causes of these disorders can vary greatly; and are dependent on problems in two types of self-control: emotions (e.g., anger and irritation) and behaviors (e.g., aggression, argumentativeness, defiance). These disorders tend to be more common in boys than girls and have first onset during childhood or adolescence. Many of the symptoms that define these disorders can occur to a lesser degree in typically developing children and adolescents.

Interestingly, disruptive behavior disorders are frequently comorbid; that is, an individual may have more than one diagnosis within the category. Of note, attention deficit-hyperactivity disorder (ADHD)Opens in new window was included with disruptive disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); however, it is included with the neurodevelopmental disorders in DSM-5 (American Psychiatric Association, 2013, pp. 15 – 16).

Description of the Conditions

Oppositional Defiant Disorder (ODD)

ODD often manifests early and can be identified as early as preschool. It is a relatively common disorder with an estimated lifetime prevalence between 2 and 16% for males and 2 and 9% for females (APA, 2013; Nock, Kazdin, Hiripi, & Kesler, 2007).

To meet the criteria for ODD, an individual must display a pattern of defiance lasting at least 6 months as evidenced by at least four symptoms from the categories of angry/irritable mood (e.g., is often touchy or easily annoyed), argumentative/defiant behavior (e.g., often actively defies or refuses to comply with requests from authority figures or with rules), and vindictiveness (e.g., spitefulness). These symptoms must be exhibited during an interaction with at least one individual who is not a sibling (APA, 2013, pp. 219 – 220).

According to the DSM-5, the persistence and frequency of these behaviors can differentiate between a behavior that is within normal limits and one that is symptomatic. For children under age 5, these behaviors should last for 6 months and occur on most days. For individuals older than 5, the behaviors should last for the duration of at least 6 months and occur at least one time per week. An individual’s developmental level, gender, and culture should be considered while determining whether the frequency and duration are outside a normative range.

Intermittent Explosive Disorder

The disorder is manifested by verbal aggression (e.g., temper tantrums, tirades, verbal arguments, or fights) or physical aggression toward property, animals, or other individuals.

To meet diagnostic criteria, these behavior outbursts must occur twice weekly, on average, for a period of 3 months. Or, the individual must have three behavioral outbursts involving damage of property and/or physical assault involving physical injury against animals or other individuals within a 12-month period.

The magnitude of the individual’s recurrent outbursts must be grossly out of proportion to the provocation or to any precipitating psychosocial stressors. They must not be premeditated or committed to achieve a tangible objective, such as money, power, or intimidation.

The outbursts must cause the individual marked distress or impairment in occupational or interpersonal functioning, or there must be associated financial or legal consequences. Individuals diagnosed with intermittent explosive disorder must be at least 6 years of age or at an equivalent developmental level. For children ages 6 to 18, aggressive behaviors associated with an adjustment disorder should not be considered for this diagnosis (APA, 2013, p. 221).

Conduct Disorder

The symptoms of conduct disorder fall into four categories:

1. Aggression to people and animals (e.g., often initiates physical fights or has been physically cruel to animals)
2. Destruction of property (e.g., has deliberately engaged in fire setting with the intention of causing serious damage)
3. Deceitfulness or theft (e.g., has stolen items of nontrivial value without confronting a victim or shoplifting without breaking and entering)
4. Serious violations of rules (e.g., is often truant from school, beginning before age 13 years)

To be diagnosed with conduct disorderOpens in new window, the disturbance in the individual’s behavior must cause clinically significant impairment in social, academic, and/or occupational functioning. If the individual considered for this diagnosis is 18 years of age or older, s/he must not meet criteria for the diagnosis of antisocial personality disorder (APA, 2013, p. 222).

Antisocial Personality Disorder

Antisocial personality disorderOpens in new window falls under the broader category of Personality Disorders in the DSM-5. The diagnosis of antisocial personality disorder is only given to individuals 18 years of age and older and only if there is a history of symptoms of conduct disorder before age 15.

Characteristics for this disorder include a pervasive pattern of disregard for and violation of the rights of others. An individual must display three or more of seven specified behaviors, such as failure to conform to social norms with respect to lawful behaviors, deceitfulness, irritability and aggressiveness, reckless disregard for safety of self or others, and lack of remorse.

Pyromania

The individual experiences tension or arousal before the act of fire-setting and a sense of relief or pleasure in the fire’s aftermath. Individuals with pyromania have an intense fascination with fire.

Fire-setting is a dangerous and challenging behavior to manage, but it is not always predictive of later diagnosis of pyromania. Children and adolescents, in particular, may experiment or use fire-setting as a challenge to authority, but are not fixated on the fire itself or its outcomes (Bowling & Omar, 2014). When diagnosed, in occupational terms, this may be noted as an extreme “preoccupation’ with fire that interferes with other occupations.

PyromaniaOpens in new window is associated with other types of impulsive behavior including alcohol and marijuana use disorders and conduct disorder, as well as histories of trauma (Huff, 2014; Vaughn et al., 2010).

Kleptomania

The stolen objects are not needed for personal use or for their monetary value, the stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination, and the stealing is not better explained by another disorder.

Kleptomania, which is a relatively rare disorder, needs to be differentiated from patterns of stealing or shoplifting that are relatively common behaviors among those of all ages (Schreiber, Odlaug, & Grant, 2011). KleptomaniaOpens in new window has been diagnosed and treated in children (Yilmaz & Bilgic, 2014) as well as adults across cultures with some promising outcomes (Christianimi et al., 2015).

Etiology of Impulse Control Disorders

Research efforts continue to investigate factors that influence the development and age of onset of disruptive behavior disorders. Because these conditions are often accompanied by other psychiatric diagnosis, such as ADHDOpens in new window and fetal alcohol syndrome (FAS)Opens in new window, it is sometimes difficult to specify a causative factor (Centers for Disease Control & Prevention [CDC], 2013).

Genetics and parenting have been identified as factors that influence the development of disruptive disorders. Alemany et al., (2013) looked at genetic associations through the study of twin pairs. Parental negativity and the evolution of behavior problems were analyzed, noting a high influence of heredity at age 4 years with a slight reduction of influence by age 12 years, when common environmental influence was more strongly factored in.

Parent and colleagues (2011) found that “harsh discipline was related to disruptive behavior of both boys and girls, whereas only permissive discipline was related to disruptive behavior of boys” (p. 531).

Corporal punishment has been linked in male adolescents to conduct problems, including problems with self-control and a “hostile view” of relationships for both males and females. Verbal abuse is noted to create anger and a “hostile view” in both males and females.

Environmental factors that have been shown to influence the emergence and diagnosis of disruptive behaviors include classroom atmosphere and management and a history of trauma, maltreatment, and neglect. An Icelandic study noted that for girls, consumption of excessive amounts of caffeine (e.g., sports drinks) has been linked to both “violent behaviors and conduct disorders” (Kristjansson et al., 2013).

Unhealthy sleep patterns may also contribute to or exacerbate patterns of oppositional defiance and other conduct problems among adolescents (Lin & Yi, 2015).

Some researchers suggest that a lack of early intervention for childhood problem behaviors may lead to the presence of more severe disorders, such as conduct disorder in adolescence and psychopathology in adulthood (Dodge et al., 2015).

Ongoing neurological research suggests low responsivity in the amygdale is an underlying factor in the development of disruptive behavior disorders (Bertocci et al., 2014; Finger et al., 2011; White et al., 2012). Reduced “connectivity” between the amygdale and the prefrontal cortex is believed to influence the effectiveness of “automatic” emotional regulation and subsequent behaviors (Bertocci et al., 2014). The individual may subsequently react before s/he can effectively assess a situation that triggers an emotional response.

Discovering underlying factors that influence behavioral regulation may provide more insight regarding intervention and the potential progression of behavioral challenges through time. Similarly, Larson and colleagues (2013) noted that adults diagnosed with psychopathology may become so fixated or “goal directed” that they are unresponsive to environmental cues that would typically come from the amygdale to the prefrontal cortex, including those that evoke fear or startle.

Intervention

This segment of the literature outlines common intervention approaches for individuals with disruptive behavior disorders.

Psychosocial Interventions

Interventions for severe oppositional defiant, conduct, and intermittent explosive disorders focus on correcting firmly entrenched patterns such as blaming others and denial of responsibility for personal actions.

Children, adolescents, and adults with these disorders also must generate more mature and adaptive coping mechanisms and prosocial goals, a process that is gradual and cannot be accomplished during short-term treatment.

General interventions include the following:

1. Promote a climate of safety for the patient and for others.
2. Establish rapport with the patient.
3. Set limits and expectations.
4. Consistently follow through with consequences of rule-breaking.
5. Provide structure and boundaries.
6. Provide activities and opportunities for achievement of goals to promote a sense of purpose.

Oppositional youth are generally treated on an outpatient basis, using individual, group, and family therapy, with much of the focus on parenting issues. In conduct disorder, inpatient hospitalization for crisis intervention, evaluation, and treatment planning, as well as transfer to therapeutic foster care, group homes, or long-term residential treatment, are often needed.

Unfortunately, studies indicate that many children and adolescents placed in group homes and in some residential programs do not gain improvements after therapy. However, intensive programs such as multisystemic therapy, therapeutic foster care, and use of multidisciplinary community-based treatment teams for children with serious emotional and behavioral disturbances have been found to improve outcome and reduce offenses over the long term. These types of programs are more promising in improving positive adjustment, decreasing negative behaviors, and improving family stability.

Pharmacological Interventions

A variety of medications are used to control aggression. They include tricyclic antidepressants, antianxiety medications, mood stabilizers, and antipsychotics (Taylor et al., 2014).

Recognizing and treating aggressive and impulsive behaviors while a person is young can prevent further problems and avoid interactions with the criminal justice system. Unfortunately, stigma and misconceptions around mental illness may cause individuals and their families to conceal these conditions. Concealment can limit help-seeking and professional care, preventing timely intervention.

Advanced Practice Interventions

Advanced practice psychiatric-mental health registered nurses may use a variety of psychosocial interventions that target pathology associated with impulse control disorders. The overall goals are to (1) help patients maintain control of their thoughts and behaviors and (2) assist families to function more adaptively.

1.   Cognitive-Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) is an evidenced-based treatment approach that can be used for children, adolescents, and adults. It is a talk therapy that focuses on a patient’s feelings, thoughts, and behaviors.

CBT is based on the idea that if we change our thoughts to be more realistic and positive, we can change the way we experience life. Cognitive therapy teaches patients to recognize the onset of the impulse to explode or act aggressively, to identify circumstances or triggers associated with the onset, and to develop methods to prevent the maladaptive behaviors from occurring.

2.   Psychodynamic Psychotherapy

One of the older treatment approaches, psychodynamic psychotherapy, continues to have relevance. Its focus is on underlying feelings and motivations and explores conscious and unconscious thought processes. In working with impulse control problems, the therapist may help the patient to uncover underlying feelings and reasons behind rage or anger. This may help patients to develop better ways to think and control their behavior.

3.   Dialectical Behavioral Therapy (DBT)

A specific kind of cognitive behavioral treatment that has a focus on impulse control is dialectical behavioral therapy (DBT). Skills taught include mindfulness, emotional regulation, distress tolerance, and personal effectiveness (Cooper & Parsons, 2010). Shelton and colleagues (2011) found a DBT-Corrections Modified version of this therapy to be effective in reducing physical aggression in incarcerated adolescents.

4.   Parent-Child Interaction Therapy (PCIT)

Another evidence-based approach is parent-child interaction therapy (PCIT). Therapists such as advanced practice nurses sit behind one-way mirrors and coach parents through an ear audio device while they interact with their children.

The advanced practice nurse or other advanced practice provider (e.g., psychiatrist, psychologist, counselor, or therapist) can suggest strategies that reinforce positive behavior in the child or adolescent. The goal is to improve parenting strategies and thereby reduce problematic behavior.

5.   Parent Management Training (PMT)

Parent management training (PMT) has a 65% success rate in significantly improving behavioral problems in children diagnosed with oppositional defiant disorder and conduct disorder (Kazdin, 2005).

This evidence-based treatment is for children aged 2 to 14 with mild to severe behavioral problems.

Parents of children with oppositional defiant disorderOpens in new window and conduct disorderOpens in new window tend to engage in patterns of negative interactions, ineffective harsh punishments, emotionally charged commands and comments, and poor modeling of appropriate behaviors. This treatment targets the parents rather than the child and focuses attention on reinforcement of positive and prosocial behavior, and on brief, negative consequences of bad behavior.

6.   Multisystemic Therapy (MST)

Of all the treatment approaches presented in this list, multisystemic therapy (MST) is the most extensive. This evidence-based approach is an intensive family and community-based program that takes into consideration all of the environments of violent juvenile offenders.

Therapists work with caregivers who are on call 24 hours a day, 7 days a week to go where the child is. Hanging out with friends is replaced with healthy activities such as sports or recreational activities. MST can improve family functioning, school performance, and peer relationships and can build meaningful social supports (Henggeler et al., 2009).