Introduction
In the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, Behavioral Disorders are classified within the chapter entitled “Disruptive, Impulse-Control and Conduct Disorders.” In the previous edition of the DSM (DSM-IV-TR), Behavioral addictions were included within the impulse control disorders classification. The chapter in the DSM-5, however, further specifies disorders that are behavior based, and separates out addiction-related disorders, which are classified in the chapter titled “Substance-Related and Addictive Disorders.”
Disorders included within the DSM-5 chapter of “Disruptive, Impulse-Control and Conduct Disorders” include those which were previously encapsulated in other chapters of the DSM-IV-TR. These include Oppositional Defiant Disorder and Conduct Disorder, which were previously classified in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence;” and Intermittent Explosive Disorder, Pyromania, and Kleptomania, which were previously classified as “Impulse-Control Disorders Not Otherwise Specified” in the DSM-IV-TR. The underlying tie for these disorders, which led to them being classified together in the DSM-5, is difficulty with emotional or behavioral self-control. Also of note for this chapter, Antisocial Personality Disorder is described in both this chapter, as well as the chapter on personality disorders. The DSM-5 eliminated the multi-axial diagnostic system which was present in the DSM-IV-TR (as well as many previous editions), in favor of listing disorders based more so on their degree of impact on the psycho-social functioning of the individual. Attention Deficit/Hyperactive Disorder (ADHD), which is often comorbid with many of the disorders in this chapter, is classified under the DSM-5 chapter titled “Neurodevelopmental Disorders.”
Oppositional Defiant Disorder (ODD): Oppositional Defiant Disorder is marked by a pattern of angry/irritable mood (e.g. often loses temper, is often touchy or easily annoyed, is often angry and resentful), argumentative/defiant behavior (e.g. often argues with authority figures, or, for children and adolescents, with adults; often actively defies or refuses to comply with requests from authority figures or with rules; often deliberately annoys others, often blames others for his or her mistakes or misbehaviors), or vindictiveness (e.g. has been spiteful or vindictive at least twice within the previous six months). The behaviors must be present for a minimum of six months, and be observable through interactions with others (who are not siblings of the individual).
Of note, the frequency and intensity of these behaviors should be used to differentiate between behaviors that are within normal limits developmentally, and those that are pathological. For example, for a child who is less than 5 years old, the behavior should generally occur on most days for a minimum period of six months. For children older than 5 years of age, the behaviors should occur at least weekly for a minimum period of six months. Additional considerations, including gender and culture should also be taken into account prior to assigning a diagnosis.
Further criteria for diagnosis include the determination that the disturbance in behavior is associated with clinically significant distress within the social context of the individual (e.g. peers, family members), and/or the behaviors negatively impact essential areas of functioning (e.g. social, education, occupational). The behaviors must not occur exclusively during the course of a psychotic, substance use, depressive or bipolar episode or disorder. The diagnostic criteria for disruptive mood dysregulation disorder, a newly created diagnosis in the DSM-5 which is defined by frequent and extreme irritability, anger, and intense temper outbursts, supersedes a diagnosis when symptoms go beyond those described in the diagnostic criteria.
The severity of the disorder is specified based on the following criteria: Mild: the symptoms are present in only one context (e.g. at school, with peers, at work, at home); Moderate: the symptoms are present in at least two settings; Severe: the symptoms are present in three or more settings.
Intermittent Explosive Disorder: Intermittent Explosive Disorder is characterized by recurrent behavioral outbursts representing a lack of control over aggressive impulses. The disorder is demonstrable by either (or both): verbally aggressive behavior (e.g. being verbally argumentative, frequent temper tantrums); physically aggressive behavior (directed towards property, animals, or others), and/or three behavioral outbursts that involve damage or destruction of property (within a 12-month period).
Additional diagnostic criteria include: the degree to which the expressed aggressiveness is present during outbursts is significantly disproportionate to the precipitating stressor; the recurrent aggressive outbursts are not premeditated or committed in pursuit of obtaining something tangible, and/or cause marked distress in the individual or impairment(s) in functioning (e.g. social, occupational) or are associated with consequences (e.g. legal, financial). In order to make a diagnosis of Intermittent Explosive Disorder, the individual must be at least six years old, and the recurrent aggressive outbursts are not better explained by another psychiatric disorder (e.g. a personality disorder, a depressive disorder, an anxiety disorder, a psychotic disorder) or the psycho-physiological effects of a substance (e.g. illicit substance, medication side effect or misuse). Lastly, when frequent and intense displays of aggressive behaviors are present in excess of those typically observed in other disorders (e.g. Autism Spectrum Disorders, Attention Deficit/Hyperactive Disorders), a diagnosis of Intermittent Explosive Disorder may also be made in addition to further and more accurately hone the focus of the treating clinician.
Conduct Disorder: Conduct Disorder is diagnosable when there is the presence of persistent behavior that intentionally violates or disregards the rights of others, or is significantly age-inappropriate and is defiant of the norms of society. Symptoms are classified under four categories: 1) Aggression towards other people or animals, such as engaging in bullying, or physically threatening behavior (with or without a weapon); being physically cruel to other people or animals; engagement in criminal behavior (such as stealing, extortion, etc.); or forcing someone into unwanted sexual activity. 2) Destruction of Property, including fire setting with the intention of causing significant damage; or the intentional destruction of another person’s property. 3) Deceitfulness or Theft, including breaking into another person’s property (e.g. car, place of business); lying to trick or manipulate another person in order to obtain a desirous object or situation; theft of objects of minimal value without directly victimizing an individual (e.g. petty shoplifting, forgery). 4) Serious Violation of Rules, such as intentionally breaking a pre-established curfew (beginning before age 13); running away from home; and truancy from school (beginning before age 13). All of the behaviors noted must cause clinically significant distress in social, academic or occupational functioning.
Several specifiers to further describe the disorder are available for a diagnosis of Conduct Disorder. For example, the diagnosis for a child who demonstrates the symptoms prior to age 10 may be specified as “Childhood-onset type.” An individual who does not present with the previously noted symptoms prior to age 10 may be classified with “Adolescent-onset type.” When a determination of symptom onset is unable to be made, a specification of “Unspecified onset” may be given.
To further detail the exact nature of the disorder, an additional specifier is available to pinpoint the area(s) of clinical focus. The specifier “With limited prosocial emotions” may be added when the individual presents with at least two of the following (within the most recent 12 month period): Lack of remorse or guilt (e.g. does not demonstrate a sense of guilt or remorse for wrongdoing, excluding remorse when anticipating being caught or punished); a callous lack of empathy (e.g. a complete and total disregard for the feelings of others); Unconcerned about performance (e.g. demonstrates a lack of concern or worry regarding poor outputs in work or at school, and often blames others for their performance); Shallow or deficient affect (e.g. is emotionally expressive in ways that seem insincere, superficial, and generally disingenuous).
The severity of the disorder is characterized as: Mild (at least three symptoms present, the minimum number to make a diagnosis), Moderate (more than three symptoms are present, and the intensity of the behavior is of moderate degree), and Severe (a substantial amount of the symptoms noted are present, and their degree of intensity results in extreme harm to others).
Antisocial Personality Disorder: The diagnostic criteria for Antisocial Personality Disorder are located in the chapter “Personality Disorders.” However, as the disorder is intimately connected to the disorders in this chapter, it is simultaneously listed in this. The DSM-5 removed the multiaxial system present in its previous editions of the DSM; and as such disorders are now listed in order of degree of impact on functioning, and not on the corresponding diagnostic axis.
Pyromania: Pyromania is defined by an intentional fire setting on multiple occasions, with a degree of psychophysiological tension or arousal prior to action. The individual demonstrates an intense curiosity, intrigue and/or attraction to fire and related objects. The person also gains pleasure, satisfaction or relief when fires are set, or there is involvement in any process following the setting of the fire. The fire setting is not done for any type of gain (e.g. monetary), for protest (e.g. ideological reasons), in the presence of another disorder (e.g. psychosis, substance use), as a cover up (e.g. to destroy evidence), or in a responsive (e.g. vengeful) manner. The fire setting behavior should also not be better explained by another disorder (e.g. conduct or antisocial personality disorder).
Kleptomania: Kleptomania is diagnosable when the individual presents with a persistent inability to resist the impulse to steal items not for their use or value. Similar to Pyromania, the person experiences a degree of psychophysiological tension or arousal prior to action, and they gain a sense of enjoyment, satisfaction or relief at the time of committing the act. The act of theft is not committed as an expression of anger or revenge, and not in response to a psychotic event (e.g. delusion or hallucination). The theft is not better explained by another disorder (e.g. conduct or antisocial personality disorder).
The chapter titled “Disruptive, Impulse-Control and Conduct Disorders” concludes with two additional disorders which encompass symptoms not accounted for by the previously described disorders. “Other Specified Disruptive, Impulse-Control and Conduct Disorder” can be diagnosed when the individual presents with clinically significant distress that impacts multiple areas of functioning, however the symptoms do not meet the necessary threshold for diagnosis of any other disorder in the chapter. This diagnosis is used when the clinician decides to convey the specific reason the individual’s symptoms do not meet the criteria for a specific disorder in the chapter. Conversely, when a clinician does not wish to explain the reason(s) for why the individual does not meet the diagnostic criteria for a specific disruptive, impulse-control or conduct disorder, a diagnosis of “Unspecified Disruptive, Impulse-Control and Conduct Disorder” may be made. This diagnosis may be of particular clinical utility when there is inadequate information to make a more definitive diagnosis.