Summary
Impulse and conduct disorders (e.g., oppositional defiant disorder, intermittent explosive disorder, conduct disorder, kleptomania, pyromania) are a group of psychiatric conditions that affect the self-regulation of emotions and behaviors. Onset usually occurs in childhood, although some impulse and conduct disorders (e.g., pyromania) are unusual in children. The disturbance in behavior significantly impairs social, academic, and/or occupational functioning. Genetic, environmental (e.g., in utero exposure to toxins), psychological, and social (e.g., physical abuse, neglect) factors are thought to play a role in the development of impulse and conduct disorders. While oppositional defiant disorder (ODD) and conduct disorder both manifest with defiance and resistance to authority, individuals with conduct disorder are more likely than individuals with ODD to engage in criminal behavior. ODD often precedes conduct disorder. Intermittent explosive disorder manifests with outbursts of impulsive aggression (verbal or physical) that are unplanned and out of proportion to the circumstances. Pyromania (compulsive fire-setting) and kleptomania (compulsive stealing) are characterized by uncontrollable impulses and often result in property damage, harm to other individuals, and/or legal consequences. Diagnosis of impulse and conduct disorders is based on DSM-5 criteria. Management involves treatment of comorbidities (e.g., ADHD and depression), psychotherapy, family and educational support (for pediatric patients), and, in severe or refractory cases, pharmacotherapy.
Disruptive mood dysregulation disorder (DMDD) also causes irritable behavior and angry outbursts in children. As DMDD is considered a depressive disorder, it is covered separately in the depressive disorders article.
Overview
Clinical features [1]
- Onset usually occurs in childhood. [1]
-
Argumentative, aggressive, or impulsive behavior; disproportionate anger
- Behaviors impact daily functioning.
- Not part of normal development (e.g., temper tantrums)
Diagnostics [2][3]
- Assess for differential diagnoses.
- Consider using screening tools (e.g., Vanderbilt assessment scale) to identify impulse and conduct disorders. [2][4]
- Refer to a psychiatrist; diagnoses are based on DSM-5 criteria.
Differential diagnoses [1][2]
- Attention deficit hyperactivity disorder
- Adjustment disorder
- Substance use disorder
- Posttraumatic stress disorder
- Neurodevelopmental disorders
- Depressive disorders, including DMDD and bipolar disorder
- Temper tantrums
- Organic causes of altered mental state
Some differential diagnoses (e.g., ADHD) may occur concurrently with impulse and conduct disorders; however, individuals with a diagnosis of DMDD cannot also be diagnosed with ODD, intermittent explosive disorder, or bipolar disorder. [1][2]
Management of impulse and conduct disorders
Management is overseen by psychiatry and tailored to the specific disorder but usually includes:
- Treatment of comorbidities, e.g.:
-
Psychosocial interventions, e.g.: [5]
- Psychotherapy (e.g., cognitive behavioral therapy) [3]
- For children: family therapy and/or support programs that involve the school [6]
- Consideration of pharmacological treatment (e.g., SSRIs, off-label risperidone) if the condition is severe and/or refractory [2][7][8]
Overview of pediatric disorders of behavior regulation
| Disruptive, impulse control, and conduct disorders in childhood [1] | |||
|---|---|---|---|
| Important findings | Prognosis | ||
| Conduct disorder |
|
| |
| Oppositional defiant disorder (ODD) |
|
| |
| Intermittent explosive disorder |
|
| |
| Disruptive mood dysregulation disorder (DMDD) |
|
| |
When differentiating between ODD and Conduct Disorder, remember: “Arguing is just ODD, but stealing CDs is a crime.” Individuals with conduct disorder are more likely than individuals with ODD to be physically aggressive and engage in criminal behavior.
Oppositional defiant disorder
ODD is characterized by anger, irritable mood, and defiance toward authority figures; behaviors significantly impair social and/or academic functioning.
Epidemiology [1]
- Onset is usually during late preschool or elementary school years.
- Before puberty ♂ > ♀; after puberty ♂ = ♀
- Frequent comorbidity of ADHD and/or learning disorders
Etiology
ODD is associated with genetic, environmental, psychological, and social factors (e.g., abuse, family history, neglect, family instability).
DSM-5 criteria for oppositional defiant disorder [1]
The following criteria must be met to diagnose ODD.
-
≥ 4 symptoms when interacting with ≥ 1 individual who is not a sibling
- Loses temper
- Easily annoyed
- Angry and/or resentful
- Argues with authority figures and/or adults
- Defies or refuses to follow rules
- Purposely irritates others
- Inappropriately assigns blame to others
- Spiteful (≥ 2 times within past 6 months)
-
Symptoms must be present for ≥ 6 months.
- Children ≤ 5 years of age: occur on most days
- Children > 5 years of age: occur at least once a week
- Behaviors cause distress for the individual and/or others
- Behaviors are not attributable to an alternative diagnosis (e.g., substance use, DMDD).
Management
See “Management of impulse and conduct disorders.”
Prognosis [1]
- ODD often precedes the onset of conduct disorder.
- Individuals are at increased risk of substance use, anxiety disorders, and major depressive disorder.
Conduct disorder
Conduct disorder is characterized by disruptive behavior that interferes with the basic rights of others and/or age-appropriate social norms. [1]
Epidemiology [1]
- Onset during childhood or adolescence
- ♂ > ♀
“C and D come before E”: Conduct Disorder is usually diagnosed before eighteen years of age.
Etiology
Conduct disorder is associated with genetic, environmental, psychological, and social factors (e.g., abuse, exposure to toxins, positive family history, neglect, family instability).
DSM-5 criteria for conduct disorder [1]
The following criteria must be met to diagnose conduct disorder.
-
≥ 3 of any of the 15 criteria in the past 12 months and at least 1 of the 15 in the past 6 months
-
Aggression toward people and animals
- Bullies, threatens, or intimidates
- Initiates fights
- Has used a lethal weapon (e.g., knife, bat, gun)
- Exhibits physically aggressive behavior toward individuals
- Demonstrates physically harmful behavior toward animals
- Has stolen with confrontation of a victim (e.g., mugging, armed robbery)
- Has exhibited sexual violence
-
Destruction of property
- Set fire with destructive intentions
- Destroyed property deliberately, other than with fire
-
Deceitfulness or theft
- Broke into a house, car, or building
- Lied for personal benefit
- Has stolen without confrontation of a victim (e.g., shoplifting, forgery)
-
Serious rule violation
- Stayed out past curfew (before 13 years of age)
- Ran away from home twice, or once if for a prolonged period
- Has been frequently truant from school (beginning before 13 years of age)
-
Aggression toward people and animals
- Impairment in functioning (e.g., at school, social settings)
- If > 18 years of age, the individual must not meet the criteria for antisocial personality disorder.
Consider alternative diagnosis (e.g., antisocial personality disorder) in adult individuals with a new onset of aggressive and disruptive behavior. [1]
Management [2]
See “Management of impulse and conduct disorders.”
Prognosis [1]
- If behaviors significantly impact functioning in adulthood, evaluate for antisocial personality disorder.
- Individuals are at increased risk of suicidal behaviors.
Intermittent explosive disorder
Intermittent explosive disorder is characterized by impulsive outbursts of aggression (verbal or physical) that are sporadic, unplanned, and disproportionate to the circumstances.
Epidemiology [1]
- ♂ > ♀
- Age at onset: 14–17 years [9]
- Prevalence: up to 7% of the general population [10]
Onset of intermittent explosive disorder is rare after the age of 40 years. [1]
Etiology
Intermittent explosive disorder is associated with genetic, neurobiological, inflammatory, infectious (e.g., Toxoplasma gondii), psychological, and social factors (e.g., history of abuse).
DSM-5 criteria for intermittent explosive disorder [1]
The following criteria must be met to diagnose intermittent explosive disorder.
-
Recurrent impulsive outbursts manifested as one of the following:
- Verbal or physical aggression, not resulting in injury or damage, on average ≥ 2 times per week for a period of > 3 months
- ≥ 3 episodes of physical violence toward other people, animals, or property over a period of 12 months
- Outburst features
- Impulsive, unplanned, and not committed for an ultimate motive
- Aggression disproportionate to the situation
- Cause significant distress, negatively impact the individual's interpersonal functioning, and/or result in legal or financial consequences
- Onset occurs at ≥ 6 years of age (or equivalent developmental level).
- Symptoms cannot be attributed to:
- Another mental disorder (e.g., DMDD, adjustment disorder)
- Medical condition (e.g., traumatic brain injury)
- Substance use
Emotional outbursts typically last < 30 minutes, and feelings of remorse, regret, or embarrassment after an outburst may occur. [1][11]
Management
See “Management of impulse and conduct disorders.”
Prognosis [1]
Self-harm may occur and aggression may continue throughout the patient's life.
Other impulse and conduct disorders
Pyromania
- Individuals cannot control the impulse to set fires, resulting in multiple episodes of intentional fire setting.
- Individuals experience internal tension before setting a fire and relief after starting or witnessing a fire.
- The fire setting is not aimed at secondary gains such as money, not driven by sociopolitical factors, not an expression of anger or vengeance, and not a response to a delusion or hallucination.
- Management includes treatment of comorbid disorders (e.g., substance use disorder) and CBT. [12]
Onset of pyromania in children is rare; children or adolescents who start fires are more likely to have other psychiatric disorders (e.g., conduct disorder, ADHD). [1]
Kleptomania
- Individuals cannot control the impulse to steal objects that are not needed for personal use or for their monetary value.
- Individuals experience internal tension before stealing and relief at the time of committing theft.
- The stealing is not motivated by anger or vengeance and is not in response to a delusion or hallucination.
- Treatment usually involves therapy (e.g., CBT); ; naltrexone may be considered in some patients. [13]