VIEWS: 5 PAGES: 31 POSTED ON: 7/5/2011
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
"How to write algorithm"