DISRUPTIVE BEHAVIORAL DISORDER &

ANXIETY DISORDER

OUTLINE

DISRUPTIVE BEHAVIOUR DISORDER • Oppositional Defiant Disorder• Conduct Disorder

ANXIETY DISORDER• Separation Anxiety Disorder

OPPOSITIONAL DEFIANT DISORDER • Is characterized by enduring pattern of

NEGATIVISTIC, DISOBEDIENT and

HOSTILE behavior toward authority figures as well as inability to take responsibility for mistakes, leading to placing blame on others.

• Frequently argue with adults and easily get annoyed

• Have problems in peer relationship but never

resort any PHYSICAL AGGRESSION

EXAMPLES OF STUDENTS WITH

ODD• Persistent refusal to comply with instructions or

rules • Stubbornness to compromise with adults or

peers• Failing to accept responsibility • Easily annoyed, angered or irritated• Being deliberately annoying or aggravating

others • Verbal hostility to others• Deliberate testing of the limits

EPIDEMIOLOGY• Ranges from 2% to 16% of children• Typically noted by 8 years of age and not later

than adolescence• More common in male (1.4:1) prior to puberty

and equally distributed after puberty

More prevalent among CHILDREN AND ADOLESCENTS from families of LOW SOCIOECONOMIC STATUS living in inner city disadvantaged neighborhoods.

ETIOLOGY• Temperamental factors• Coercion and social learning theory in family• Low socioeconomic status

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DIAGNOSTIC CRITERIA

INVESTIGATIONS• No specific laboratory tests or pathological

findings help diagnose oppositional defiant disorder.

DIFFERENTIAL DIAGNOSIS

• Developmental - stage oppositional behavioro Duration is shorter and is not as frequent or intense

• Adjustment disordero Oppositional defiant behavior occurs temporarily in reaction to stress

• Conduct disordero More severe and include aggression toward people or animals,

destruction of property, or a pattern of theft or deceit

• Others such as ADHD, cognitive disorder and mental retardation

TREATMENT1) Psychotherapy

o Family intervention• Trains the parents in child management skills • Behavior therapy focuses on praising appropriate behavior and

ignoring undesired behavior

2) Pharmacotherapyo Comorbid disorders treated with pharmacologic agents.

COURSE AND PROGNOSIS

• Course depends ono Severity and ability of the child to develop adaptive responseo The stability over time remain variableo Persistence of symptoms poses and increased risk of additional

disorders such as conduct and substance use disorder

• The prognosis for oppositional defiant disorder in a child depends on the degree of functioning in the family and the development of comorbid psychopathology.

CONDUCT DISORDER• AGGRESSIONS and VIOLATIONS of

the rights of the others• Violations include cruelty to people and animals,

destruction of property, deceitfulness or theft and serious violation of rules.

EPIDEMIOLOGY• Estimated rates of conduct disorder among

the general population range from 1 to10%• BOY > GIRL (4 -12:1)• It occurs with greater frequency in the children

of parents with ANTISOCIAL personality disorder and ALCOHOL DEPENDENCE than in the general population.

• The prevalence of conduct disorder and antisocial behavior is associated with SOCIOECONOMIC factors.

AETIOLOGY• Parental factors

o Harsh, punitive parenting characterized by severe physical and verbal aggression is associated with the development of children maladaptive aggressive behaviors.

o Sociopathy, alcohol dependence, and substance abuse in the parents are associated with conduct disorder in their children

AETIOLOGY (CONT.)• Sociocultural Factors

o Unemployed parents, lack of a supportive social network, and lack of positive participation in community activities

o Associated findings that may influence the development of conduct disorder in urban areas are increased rates and prevalence of substance use

• Psychological factorso Children brought up in chaotic, negligent conditions often express poor

modulation of emotions, including anger, frustration, and sadness. Poor modeling of impulse control and the chronic lack of having their own needs leads to a less well-developed sense of empathy.

AETIOLOGY (CONT.)• Neurobiological factors

o low level of plasma dopamine ℬ-hydroxylaseo low 5-HIAA levels in CSF correlates with aggression and violence.

• Neurological factors• Child abuse and maltreatment• Comorbid factors

o ADHD,CNS dysfunction

Table 44-2 DSM-IV-TR Diagnostic Criteria for Conduct Disorder

A.A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:Aggression to people and animals

A. often bullies, threatens, or intimidates others B. often initiates physical fights C. has used a weapon that can cause serious physical harm to others (e.g., a bat,

brick, broken bottle, knife, gun) D. has been physically cruel to people E. has been physically cruel to animals F. has stolen while confronting a victim (e.g., mugging, purse snatching, extortion,

armed robbery) G. has forced someone into sexual activity

B.Destruction of property A. has deliberately engaged in fire setting with the intention of causing serious

damage B. has deliberately destroyed others' property (other than by fire setting)

C.Deceitfulness or theft A. has broken into someone else's house, building, or car B. often lies to obtain goods or favors or to avoid obligations (i.e., “cons†others) �C. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting,

but without breaking and entering; forgery)D.Serious violations of rules

A. often stays out at night despite parental prohibitions, beginning before age 13 years

B. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)

C. is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Code based on age at onset:   Conduct disorder, childhood-onset type: onset of at least one criterion characteristic of conduct disorder prior to age 10 years   Conduct disorder, adolescent-onset type: absence of any criteria characteristic of conduct disorder prior to age 10 years   Conduct disorder, unspecified onset: age at onset is not knownSpecify severity:   Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others   Moderate: number of conduct problems and effect on others intermediate between mild and severe   Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others

DIFFERENTIAL DIAGNOSIS

• Oppositional Defiant Disordero Hostility and negativism fall short of seriously

violating the rights of other• Mood disorders

- Often present in those children who exhibit irritability and aggressive behaviour

• Major depressive disorder and Bipolar 1 disorder- Must be ruled out

• ADHDo Impulsive and aggressive behaviour is not as

severe

TREATMENT• Psychotherapy

o Individual or family education & therapyo Behavioral interventiono Social skill training

• Pharmacotherapyo Antipsychotics (haloperidol, risperidone, olanzapine)o Lithium

COURSE AND PROGNOSIS

• Severe cases are most vulnerable to comorbid disorders later in life (substance abuse, mood disorder)

• Precursor to antisocial personality disorder• Good prognosis is predicted in mild cases in the

absence of coexisting psychopathology and normal intellectual function

Differences ODD and CD

ODD

No physical aggression

Toward authority

figures only

No violation of

right

CDPresence of

physical aggression

Toward everything

Violation of right

SEPARATION ANXIETY DISORDER

• Increased and INAPPROPRIATE ANXIETY around separation from attachment figures or home, which is developmentally abnormal and results in impaired normal functioning.

EPIDEMIOLOGY• Estimated about 4% in children and young

adolescent• More common in children• Boys= girls• Most common in 7 to 8 year old children

ETIOLOGY• Bio psychosocial factors

- Neurophysiological correlation of behavioral inhibition- Quality of maternal attachment- External life stresses often coincide with the development of disorder

• Learning factors- Phobic anxiety may be communicated from parents to children by

direct modeling

• Genetic factorso Biological offspring of adults with anxiety disorders are prone to suffer

from separation anxiety disorder in childhood.

Table 50.3-1 DSM-IV-TR Diagnostic Criteria for Separation Anxiety Disorder

A.Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

A. recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

B. persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

C. persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

D. persistent reluctance or refusal to go to school or elsewhere because of fear of separation

E. persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

F. persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

G. repeated nightmares involving the theme of separation H. repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated B. The duration of the disturbance is at least 4 weeks. C. The onset is before age 18 years. D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. E. The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia.

Specify if:Early onset: if onset occurs before age 6 years

INVESTIGATIONS• No specific laboratory investigations

DIFFERENTIAL DIAGNOSIS

• Normal anxiety• Generalized anxiety disorder - Anxiety not focused on separation• Depressive disorder• Panic disorder with agoraphobia - Does not manifest until 18 years of age.

TREATMENT• Psychotherapy• Cognitive behavioral therapy• Family intervention• Pharmacotherapy• SSRI• (Diphenhydramine, Benzodiazapine alprazolam,

clonazepam)

COURSE AND PROGNOSIS

• The course and the prognosis of separation anxiety disorder, generalized anxiety, and social phobia are varied and are related to the age of onset, the duration of the symptoms, and the development of comorbid anxiety and depressive disorders.

• Early age of onset and later age at diagnosis were factors that predicted slower recovery

REFERENCES• Sadock, Benjamin James; Sadock, Virginia Alcott

Title: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Association