Psychotherapy for Impulse-Control and Conduct Disorders in Individuals
Age: 14 years
Source: Parent(mother) and the patient
Race: African American.
CC (chief complaint): “My son is constantly being chased out of school, and I think he might be having a mental problem.”
HPI: J.B is a 14-year-old male brought in by his mother who thinks that her son might be having a mental problem because he is constantly chased out of school. She reports that she has consistently been summoned to school following her son’s suspension. In fact, her son has been taken to three different schools over the last two years.
According to the mother, her son has been suspended for bullying and fighting other students. In the first school, he was suspended twice for bullying other students and then expelled after disobeying his class teacher. In the second school, he was expelled for fighting and stealing other students’ property. In his current school, he was suspended three days ago after it was noted that he was not doing his assignments, skipped classes, and failed to attend school. When asked where he was, he said he hated school and preferred to be in the streets.
At home, he is constantly arguing and fighting with her younger sister. He even threatened to kill her cat. He disobeys his parents, especially his father, who he reports mistreated her when his mother left the home. Finally, he likes stealing and vandalizing his neighbors’ property. However, there is no history of hallucinations, depression, delusions, anxiety, or sleep disturbances.
Past Psychiatric History: The patient has not been treated for substance use or mental illness previously.
- General Statement:
- Caregivers (if applicable): Parents
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with any psychiatric condition or started on any form of psychotherapy.
Substance Current Use and History: The patient denies any history of tobacco smoking, alcohol use, or illicit drug abuse. He also denies caffeine use. However, he admits that he once smoked marijuana under the influence with his friends and has never repeated it.
Family Psychiatric/Substance Use History: His maternal grandfather died at 70 due to dementia. His maternal grandmother is 70 years and suffers from PTSD after witnessing the death of his husband and son in a tragic road traffic accident. The paternal grandfather is 72 years and a known bipolar patient. His paternal grandmother suffered postpartum depression during her last pregnancy.
The father is 45 years old and smokes marijuana. His wife describes his current behavior as extremely antisocial. His mother is 38 years old and admits to leaving her matrimonial home after securing a lucrative job in the UK when her son was five years old. He has a younger sister who is alive and well.
Psychosocial History: He is the firstborn, although he does not enjoy a harmonious relationship with his younger sister. He is in high school and enjoys bullying his colleagues. He admits he does not like school at all. He also never likes making friends and prefers staying alone.
Medical History: No history of chronic illnesses such as asthma, diabetes, or hypertension.
- Current Medications: None
- Allergies: No known food and drug allergies.
- Reproductive Hx: No sexual debut yet.
Review of Systems:
General: Denies changes in weight, easy fatigability, chills, fever, and night sweats.
HEENT: Denies blurring of vision, hearing loss, nasal congestion, ear and nasal discharge, head trauma, dysphagia, and sore throat.
Respiratory: No cough, sputum, difficulty in breathing, dyspnea, and chest congestion.
Cardiovascular: Denies awareness of heartbeat, paroxysmal nocturnal dyspnea, chest pain, orthopnea, and lower limb edema
Abdominal: Denies altered bowel habits, abdominal pain, abdominal distension, nausea and vomiting, and changes in appetite.
Genitourinary: Denies frequency, dysuria, hematuria, urinary incontinence, and nocturia.
Neurologic: Denies headaches, dizziness, convulsions, syncope, and confusion
Musculoskeletal: No joint pains, backaches, or muscle pains
Dermatologic: Denies itching, rash, sores, acne, moles, or skin eruptions.
Endocrinologic: Denies excessive urination, excessive hunger, heat or cold intolerance.
Vital Signs: Blood pressure 124/75 mmHg, temperature 98.4 F, pulse rate 80 beats/minute, respiratory rate 22 breaths/minute, saturation 95% on room air, weight 144.7 lb, height 66.1 inches, BMI 19.3, pain level 0/10.
General: An African American teenager, well kempt, appropriate for his age, not in any form of distress, difficulty maintaining eye contact, well hydrated, and good nutrition status. No cyanosis, pallor, jaundice, lymphadenopathy, or edema.
Head: Normocephalic, atraumatic, with even hair distribution,
Eye: both eyes present, white sclera, no conjunctival pallor, pupils equally reacting to light bilaterally, intact extraocular movements and accommodation.
Ear: Both eyes present and situated in normal position, no impaction, nontender pinna and tragus, the tympanic membrane is grey with an intact light reflex.
Nose: Both nares are present, patent, and with no discharge. No nasal septum deviation, The sinuses are nontender to palpation.
Throat: The oropharynx is moist, with a pink mucus membrane, and no erythematous lesions or exudates. The teeth are well apposed, the gums are pink and firm, and the tongue is smooth, pink, and protrudes in the midline.
Neck: Soft neck, no lymphadenopathy or thyroid enlargement.
Respiratory: Symmetrical chest that moves with respiration, no visible scars, rash, or therapeutic marks. Equal chest expansion, equal tactile fremitus, and no tenderness or masses on palpation. Resonant to percussion. Equal air entry, vesicular breath sounds in all lung zones, no wheezes, crackles, or rhonchi, and equal vocal fremitus.
Cardiovascular: Normoactive precordium, point of maximal impulse in the fifth intercostal space in the midclavicular line. S1 and S2 heard, clear and distinct. No murmurs. No distended neck veins, right and left carotid pulses 2+, no bruits or thrills. Right and left brachial and radial arteries pulse 2+ no thills. No femoral, aortic, or renal bruits. Femoral, popliteal, tibial, and dorsalis pedis arteries pulse 2+. Capillary refill less than 3 seconds in all the digits. No peripheral limb edema.
Abdomen: Abdomen moves with respiration, symmetric and of normal fullness and contour, the umbilicus is everted, and no visible striae, distended veins, or surgical scars. No tenderness or masses were noted in both light and deep palpation. The spleen and both kidneys are not palpable. The liver span is 6 cm. Tympanic to percussion. Bowel sounds are present.
Neurological: GCS 15/15, oriented to time, place, and person, intact short-term and remote memory, speech is intact, all cranial nerves function intact, intact sensory and motor function, no abnormal gait noted, good bowel and bladder function.
Musculoskeletal: Normal bulk, normotonia, power of 5/5 in all muscle groups, normoreflexia, and normal range of motion across all joints.
Skin: The skin is warm, soft, and dry, with no skin rash, pallor, cyanosis, or abnormal nail changes.
Diagnostic results: The patient demonstrates disruptive, aggressive, and criminal behavior both at home and in school. He is 14 years. It is elemental to use the DSM-5 to rule out conduct disorder. The DSM-5 defines conduct disorder as troublesome behavior that violates the basic rights of others as well as age-appropriate social norms (American Psychiatric Association, 2022).
The patient must fulfill the following DSM criteria; Must be aggressive toward people and animals, which manifests as bullying, and physical fights. The patient with conduct disorder also exhibits behaviors such as theft, deceitfulness, and destruction of property. The fourth criterion outlines the duration of the behavior, which must be at least 12 months. Furthermore, individuals with conduct disorder demonstrate serious violations of rules, including truancy and wandering away from home (American Psychiatric Association, 2022). Finally, the patient must be less than 18 years of age and demonstrates significant social, academic, and occupational functioning impairment.
Mental Status Examination: J.B, a 14-year-old African American male teenager, well-kempt, looks appropriately groomed for the environment and his age, is slightly aggressive and does not make eye contact. He is slightly uncooperative but alert and oriented to time, place, and person. His speech is coherent and spontaneous but with loud volume and tone. His affect is angry with an irritable mood. The thought process is cohesive and logical with no flight of ideas, delusions, or suicidal ideation. No hallucinations or illusions. Memory intact, good judgment but slightly poor insight.
The patient’s presentation aligns with the DSM-5 criteria for diagnosis of conduct disorder. For instance, she is 14 years old and demonstrates disorderly behavior, including aggression towards others and animals by bullying and fighting (American Psychiatric Association, 2022). Additionally, criminal behavior such as truancy, theft, and destruction of property was reported by his mother.
J.B’s behavior has also lasted more than 12 months and has impaired his social and academic fighting. According to Mohan et al. (2022), the onset of conduct disorder is usually in adolescence or childhood, with more males being affected. Finally, J.B. demonstrates risk factors for conduct disorder, including a history of childhood maltreatment and neglect and positive family history of psychopathology.
Oppositional Defiant Disorder.
Oppositional defiant disorder is a condition characterized by irritable mood, anger, and defiant behavior towards authority figures (Eskander, 2020). This disorder shares similar risk factors as conduct disorder, including child maltreatment and neglect, positive family history, and exposure to toxins (Aggarwal & Marwaha, 2022).
The DSM-5 criteria for diagnosis of oppositional defiant disorder include; more than four of the following symptoms (frequent loss of temper, easily annoyed, argumentative, defying rules, deliberately annoying, blaming others for own mistakes, and more than two episodes of vindictive behavior within the previous six months) for more than six months when interacting with another individual who is not a sibling (American Psychiatric Association, 2022).
Similarly, the disturbance should negatively impact the individual’s social, occupational, and academic functioning or cause distress to others. Finally, disruptive mood dysregulation disorder must be excluded (Aggarwal & Marwaha, 2022). J.B does not fulfill the criteria for diagnosis of oppositional defiant disorder as mood dysregulation disorder has not yet been ruled out.
Disruptive mood dysregulation disorder (DMDD)
DMDD is a condition characterized by extreme irritability and recurrent severe anger outbursts (Parker & Tavella, 2018). The age of onset is usually before ten years. The common etiologies for this condition include vitamin deficiencies, malnutrition, psychological trauma, and neurological problems.
According to DSM-5 criteria, an individual with DMDD must be between 6 and 18 years of age, must have trouble functioning at home, school, or with peers due to irritability, and must demonstrate persistent irritability and emotional outbursts as observed by peers, teachers, and parents (Parker & Tavella, 2018).
Finally, the patient must have had severe anger outbursts lasting for more than 12 months without interruption for three consecutive months, on average more than three times a week, that are grossly out of proportion to the situation and developmental level of the child (American Psychiatric Association, 2022). J.B meets most of the criteria for DMDD except for the final criteria.
The current case depicts the impact of dysregulation of emotions and behaviors in childhood and adolescence. Impaired self-regulation of emotions may manifest as several disorders collectively grouped under disruptive, impulse control, and conduct disorders. These disorders include conduct disorder, oppositional defiant disorder, DMDD, and intermittent explosive disorder.
Similarly, these disorders manifest with overlapping symptoms making the DSM-5 criteria a vital tool in diagnosis. I agree with the preceptor’s diagnosis of conduct disorder. Both conductor disorder and oppositional defiant disorder manifest with aggressive behavior, defiance, and resistance to authority in adolescence or childhood. However, criminal behavior is a feature predominantly found in conduct disorder. This case study stresses the overlapping nature of psychiatric symptoms in childhood and adolescence and the need for careful evaluation of the child’s development.
Given this case again, I would request the mother to wait outside and interview the patient calmly, which might provide additional information. Additionally, I will provide supportive listening and opportunity for questions. Finally, the ethical and moral considerations, including patient confidentiality and privacy, documentation, the establishment of therapeutic rapport, reassurance, and effective communication in a way that does not provoke anger, are paramount.
Case Formulation and Treatment Plan:
- Initiate cognitive behavioral therapy (individual and family), parent management training, and social skills programs for conduct disorder (Sagar et al., 2019).
- Positive reinforcement and penalty for undesired behavior (Sagar et al., 2019).
- Anger management training
- Community-based training
- Currently, he does not require any pharmacotherapy. However, mood stabilizers, psychostimulants, or antipsychotics may be prescribed if severe aggression.
- Follow up by the primary care provider and nurse practitioner (Sagar et al., 2019).
Aggarwal, A., & Marwaha, R. (2022). Oppositional Defiant Disorder. https://pubmed.ncbi.nlm.nih.gov/32491375/
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
Eskander, N. (2020). The psychosocial outcome of conduct and oppositional defiant disorder in children with attention deficit hyperactivity disorder. Cureus, 12(8), e9521. https://doi.org/10.7759/cureus.9521
Mohan, L., Yilanli, M., & Ray, S. (2022). Conduct Disorder. https://pubmed.ncbi.nlm.nih.gov/29261891/
Parker, G., & Tavella, G. (2018). Disruptive mood dysregulation disorder: A critical perspective. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 63(12), 813–815. https://doi.org/10.1177/0706743718789900
Sagar, R., Patra, B. N., & Patil, V. (2019). Clinical Practice Guidelines for the management of conduct disorder. Indian Journal of Psychiatry, 61(Suppl 2), 270–276. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_539_18
Psychotherapy for Impulse-Control and Conduct Disorders in Individuals Instructions
Review this week\'s Learning Resources and consider the insights they provide about impulse-control and conduct disorders. Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.