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					Challenges in
diagnosis of
antisocial behaviors
 The   classification & diagnosis of
  conduct disorder is a controversial &
  unsettled issue in mental health
  (Frick et al,1994)
 All the classification systems for
  antisocial behavior are not fully
  valid for their developmental &
  predictive significance (Wiener &
  Dulcan,2004)
Diagnosis of CD

 Broad range of problematic behavior
 Different types of behavior (school truancy
  & running away, rape & assault)
 Severity: it indicate very different kind of
  symptoms rather than degree of the same
  symptomatology

 Behavioral criteria without reference to
  etiology-----different underlying
  psychopathology
 Fight because of
     paranoid ideation
     Impulsivity & emotional instability secondary to organic
      impairment
     Teasing

   Very heterogonous group of patients
   Conduct disorder diagnosis is not stable
     Many  children with initial diagnosis of conduct
      disorder had another diagnosis
DSM IV
   The impact of social context --- change the
    diagnosis??
     Behavior  not simply a reaction to the immediate social
      context (protective)
   Subdivision: childhood onset , adolescent onset
     Prognostic  significance not diagnostic significance
     More likely to develop adult antisocial
     More aggressive behavior
     More social rejection
CD & Antisocial personality
disorder
 Axis I or axis II diagnosis
 Conduct problems predictive of antisocial
  personality disorder
     Neuropsychiatry  & cognitive vulnerability
     Violent upbringing
   More predictive of subsequent mood
    disorder, somatoform disorder, anxiety
    disorder & substance abuse
ICD 10
   Combination category that represent co-
    occurring condition :
     ADHD
     Depression

   Subdivision:
     Family  context
     Socialization (socialized-unsocialized)
          Socialized have better prognosis
Relation between ODD & CD
   DSM : ODD is a milder form of CD
    A   developmental precursor of CD
   ICD : ODD is subcategory of CD
     Defiance is primitive & safer expression of
      aggression
   ODD in young children more predictive of
    mood disorder than CD
Other classifications
Aggressive behavior :
 Predatory (proactive) aggression:
     Goal directed
     Minimal autonomic manifestations
     More delinquent

   Affective (reactive) aggression
     Minimal instrumental gain
     High level of emotional & autonomic arousal
Overt versus covert behavior:
 Overt behavior:
     Physical & verbal aggression
     Direct & obvious

   Covert aggression
     Stealing & fire setting
     No direct & open confrontation
2 symptoms clusters
 Primary problem in aggression
 Significant problem in theft
Different
 Family structure
 Response to treatment
Callous & unemotional trait
   Callous: lack of empathy & manipulativeness
   Unemotional : lack of guilt & emotional
    constrictiveness
   Conduct with callousness :
     Greater number & variety of conduct problems
     More police contact
     Higher level of IQ
     Higher conduct problem regardless quality of
      parenting (distinct casual factor)
Children with callous & unemotional
 trait
 Reduce activity of amydgala while
  processing fearful experience
 Increase grey matter concentration in
  medial orbitofrontal & anterior cingulate
  cortex (delay cortical maturation)
 DSMV
Gender difference
CD more in males why???
 Symptoms
     Female  less overt aggression
     Female  more verbal aggression (public humiliation)
     Female  more relational aggression (dispute the
      reputation of other girls)
     More social aggression (social exclusion)
     Very few girls commit rape
     More internalizing disorders
   Group involvement in delinquent behaviors
     more   in girls
   Broad the concept of aggression & other
    symptoms to be gender neutral (DSMV)
Comorbidity
Is it true comorbidity ??
Or the conduct behaviors are part of a
 primary diagnosis ??

   All 15 behaviors defining conduct disorder occur
    as a part of other diagnosis

   Common manifestations of other psychiatric
    disorders in children are disruptive & antisocial
    behaviors

   Children with conduct disorder compared to
    children with other diagnosis:
      More symptoms of MDD
      More Dysthymia
      More GAD
      More somatic symptoms
      More withdrawn
      More thought problems
      More impaired
ADHD
ADHD & CD sharing the same deficits:
 Self regulation
 Executive functions
 Frontal lobe cognitive functions:
   Foresight
   Judgment
   Impulse   control
ADHD & CD sharing the same symptoms:
 Impulsiveness
 Short attention span
 Overactivity
 Social inappropriate behavior
 Poor judgment
 School difficulties
   Significant number of children with initial
    diagnosis as CD are found to have ADHD
    at follow-up
Depression
   Symptoms of CD may start & stop with the onset
    & recovery from mood disorder
   Depression like symptoms present in patients
    with CD
   Depressive subtype of conduct:
     Fewer biological depressive symptoms
     Fewer anxiety symptoms
     Less guilt
     Less depressive severity than MDD without CD
     Less overt aggression & violence than CD without
      depression
Suicide
   Predictors of suicide outcome among
    males
     Conduct   disorder
     ADHD
     Emotional   problems
   Within the comorbid groups
        conduct-emotional status (ie, children who
        are impulsive and aggressive and at the same
        time have emotional problems)
Mania
Mania & hypomania in children &
  adolescents may present with:
 Episode of violence
 Poor judgment
 Social inappropriateness
Repeated instances of antisocial behaviors
   In recent study 50% of incarcerated youth met
    the diagnostic criteria of mania

   Overlooked?
     Grandiosity
     Boastfulness
     Apparent lack of empathy
     Heedlessness of the consequence of their acts
     Seen as narcissistic & psychopath

   Careful mood history
   Documentation of periodicity of obnoxious &
    destructive behavior
Psychotic disorders
   Psychotic symptoms in adolescents associated
    with severe violence
   The most common psychiatric symptoms
    associated with severe violence :
     Thought control
     Thought insertion
     Paranoid ideation

   The more violent & bizarre the adolescent the
    more likely the existence of underlying psychotic
    symptoms
 Adolescents with psychotic disorders
  strive to minimize their symptoms
  (delusion & hallucination)
 They prefer to be bad rather than crazy
 They desire to appear normal
Mental retardation &
learning disabilities
 Low-normal scored on IQ tests
 Occur as early as 3 years (not result of
  school failure)
 Disadvantaged background
 Intrinsic limitation or environmental
  adversity (treatment implication)
 Deficits of verbal skills (account for low IQ)
 PIQ is significantly higher than VIQ
 Learning disability (reading problems)
 Inherit deficit or dysfunctional environment
  (actions tend to speak louder than words)
What is more important than
diagnosis of CD
 Other psychiatric diagnosis
 Cognitive functions
 Temperament
 Functioning (school, socialization)
 Family & environmental context
 Psychopathology (understand why?)
The more sophisticated the
 clinician the less he will simply
 diagnosed conduct disorder

				
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