This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.
Disruptive, Impulse-Control, & Conduct Disorders in the DSM-5 by Hailey Hinkle
One of the biggest changes to occur from the DSM IV to the DSM 5 was that there was a new chapter of disorders created called disruptive, impulse-control, and conduct disorders. This class combined different disorders together that presented problems with self control regarding behaviors (compliance, violence, trouble with the law), emotions, and impulsivity. The majority of the disruptive, impulse-control and conduct disorders came from the two different sections called “disorders usually first diagnosed in infancy, childhood, or adolescence” and “impulse control disorders not otherwise specified”.
The first section of the disorders occurring in infancy, childhood, or adolescences contained oppositional defiant disorder (ODD), conduct disorder, and disruptive behavior disorder not otherwise specified. Disruptive behavior disorder not otherwise specified has been removed from the DSM 5 and is now being called specified and unspecified disruptive, impulse-control, and conduct disorders. The next section of disorders came from impulse-control disorders not otherwise specified. This contains intermittent explosive disorder, pyromania, and kleptomania. They also gave dual disorder listing to antisocial personality disorder. It is now listed in the disruptive, impulse-control, and conduct disorders as well as the personality disorders. The argument was that conduct disorder and antisocial personality disorder are closely associated together because of presenting symptomology. The DSM 5 disruptive, impulse-control and conduct disorders section has oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, kleptomania, and other specified/unspecified disruptive, impulsive, and conduct disorders.
When the DSM was being revised, changes started to occur in categorization of disorders. The DSM 5 eliminated the section disorders usually first diagnosed in infancy, childhood, or adolescence. These disorders got separated accordingly. While the majority of the disorders were categorized in the disruptive, impulse-control and conduct disorders, some disorders went elsewhere. For example, Attention Deficit/Hyperactivity Disorder (better known as ADHD) was moved into the nuerodevelopmental disorders section. ADHD is frequently co-morbid with many of the disruptive, impulse-control, and conduct disorders. It is not uncommon for someone to experience behavior problems in both areas of attention deficit and hyperactivity.
The first disorder to undergo changes in the disruptive, impulse-control, and conduct disorder section was oppositional defiant disorder. There were four major changes to diagnosis. The first change declared three different subtypes of oppositional defiant disorder. They can now be categorized into anger/irritable mood, argumentative and defiant behaviors, and vindictiveness. This allows the disorder to describe emotional and behavioral problems with different symptomology expression. These subtypes allocate for individual differences. The next big change in ODD is that conduct disorder is no longer excluded from a co-morbid diagnosis. ODD is being viewed as precursor for conduct disorder. It is less severe and a diagnosis of conduct disorder no longer eliminates someone from being diagnosed with oppositional defiant disorder. The third change encourages data collection to take place in order to proof that the behavioral symptoms are occurring more often with the individual than with their peer group. This helps clearly define the dysfunction and shows it as a maladaptive trait that could be interfering with someone’s well being. Lastly a severity rating has been added to diagnosis. There is a mild, moderate, or severe diagnosis. This allows for a more individualized approach to the disorder and helps provide an understanding of the unique levels of impairment. The main component of this disorder is the behavior. They are individualized depending upon the person learned history, environment, and parenting styles. It is really rare to see two people with oppositional defiant disorder acting in the exact same one. These change help evaluating the unique circumstances in which oppositional defiant disorder can occur.
Conduct disorder remained fairly close to its DSM IV diagnosis. They added a new specifier for the disorder regarding prosocial emotions. This is for individuals who meet the full criteria of conduct disorder but have a lack of understanding regarding socially appropriate behaviors, emotions, and rules. These individuals are mostly callous and unemotional in their responses. Their interpersonal relationships are not strong or typical of their peers. These apathetic and cold behaviors can occur across multiple settings and relationship. Other behaviors that someone with conduct disorder with limited prosocial behaviors might have are a lack of remorse or guilt, indifference about performance, and shallow or deficient affect. This type of diagnosis is often harder to treat and requires a different approach to therapy than others with conduct disorder.
The last group of changes between the DSM IV and the DSM 5 falls in the intermittent explosive disorder. It now allows for aggressive outburst to come in two different forms: verbal aggression and non-destructive/non-injurious physical aggression. These were added to the DSM IV description of physical aggression. Now all three types of aggression are acceptable for diagnosis in the DSM 5. They also added an age requirement to the disorder to help distinguish between intermittent explosive disorder and typical temper tantrums. In order to receive this diagnosis the individual has to be at least six years old. The next big change in the DSM 5 is that it better clarifies intermittent explosive disorder with the following disorders: mood dysregulation disorder, antisocial personality disorder, borderline personality disorder, medical condition changes, nuero-cognitive disorders, substance related disorders, autism spectrum disorder, conduct disorder, attention deficit/hyperactivity disorder, or oppositional defiant disorder. This change in diagnosis allows for better clarification of intermittent explosive disorder in regards to child and adolescent presentation. There was also a frequency measure added to the diagnostic symptoms describing the functions of behavior as either aggressive outbursts or impulsive or anger based. Lastly, there must be some level of functional consequences for the individual. These types of behavior need to have some level of impairment, distress, or dysfunction weather that is social, occupational, financial or legal.
These changes that have occurred in the DSM 5 greatly improve diagnostic criteria and help shape the beginning for disruptive, impulse-control, and conduct disorders class. It eliminates a broad diagnostic group like Disorders Usually Developed in Infancy, Childhood, and Adolescences while improving the organizational structure of the DSM 5. The specific group changes in oppositional defiant disorder, conduct disorder, and intermittent explosive disorder improve dimensional qualities while allowing for individual differences in expression.