Comprehensive Psychiatric Evaluation: Conduct Disorder

Subjective Section

Biodata

Name: J

Sex: Male

Age: 13 years

Nationality/Ethnicity: American

Residence: Berkeley town, West Virginia

Admission: Involuntary

Informant: Mother and school teacher

Chief Complaint: “My son does not follow instructions and behaves in socially unacceptable ways for the past 3 years now”. The mother reports

Comprehensive Psychiatric Evaluation: Conduct Disorder

History of Presenting Illness:

J, a 13-year-old boy from Berkeley, West Virginia, arrives at an outpatient psychiatric clinic in the company of his mother and schoolteacher. The mother complains that J does not follow instructions and continually engages in “socially inappropriate” conduct. Because it was a school day and a weekday, the mother gained permission from the school to seek psychiatric treatment, and she sought the companionship of J’s school teacher to explain certain issues.

Despite being reminded severally, J does not do his household responsibilities, which include cleaning the bathroom and emptying the trash can. Furthermore, despite parental prohibitions and caution to always return home earlier before the night comes, he plays football, his hobby, till late at night. In addition, the mother notes that J remains up late watching television despite repeated efforts to make him sleep earlier and that he often does not turn off the television even after he goes to sleep.

At home, he also provokes violent confrontations with his older brothers for trivial issues such as a missing television remote, and they resent him for it. In addition, his father constantly chastises him for his actions, which is the source of his cold relationship with his father.

J has skipped school twice in the previous week, according to the teacher, although his mother claims he has never stayed at home on a school day. He fails to complete assignments, and his performance has significantly deteriorated. He is meant to be in grade 8, but he is still in grade 6, due to a string of bad performances, which he seems unconcerned about.

He has changed schools twice since the age of eight, once owing to his father’s relocation to a new town and once due to a serious breach of the school’s regulations. He has had regular run-ins with the school’s principal for bullying other students, which has resulted in his being suspended twice in the previous three months. He readily gets into violent conflicts with his peers and classmates, which is why he has few friends and does not keep old ones.

He has been reported for stealing his classmates’ course books and purposely rip certain pages without remorse. His misbehavior has landed him in front of the class, where he can be readily observed. When questioned why he harms his colleagues and peers, he blames them for wrongdoings, which is not the case. His continual “socially unacceptable” patterns of conduct at school and home caused his mother to become concerned and seek psychiatric help for him.

Past Psychiatric History: At the age of eight, he was diagnosed with the oppositional defiant disorder (ODD) owing to his irritable, argumentative, and vindictive tendencies. His therapist then resorted to helping him with parent and family training programs to help him manage his condition. Thus, this is the second time he is seeking psychiatric care.

Medication Trials and Current Medications: No history of psychopharmacologic trials, in the past or at present.

Psychotherapy or Previous Psychiatric Diagnoses: His mother participated in a three-month parent-child interaction therapy program, attending one session per week and receiving real-time coaching on how to better handle her child’s condition. She coexisted peacefully with his son after the treatment until his latest overwhelming, disruptive conduct.

Pertinent Substance Use: Denies history of substance abuse

Family History & Social History: Both parents are alive. The father is 56 years old, an accountant who has been terminated twice because of his excessive drinking habits. The mother is 50 years old, runs a small-scale textile company, and lives a healthy lifestyle. Both contribute to the family’s well-being, both monetarily and in other ways.

He is the third of three children. The first child is John, a 26-year-old male electrical engineer who has had an encounter with the police once for physically assaulting a coworker; the second child is Tywin, a 19-year-old man who just graduated high school and has yet to enroll in accounting school; he has a history of marijuana usage. The patient is the third and last born, and he is in grade 6 in middle school, which is behind for his age.

Medical/Surgical History: Previous hospitalization for gastroenteritis 5 years ago. He also had treatment for iron deficiency anemia when he was 10 years old. When he was five years old, he had an exploratory laparotomy as a result of a blunt abdominal trauma that induced pneumoperitoneum.

Allergies: No known food and drug allergies

Review of Systems:

Constitutional: Denies hotness of body, weight loss, or fatigue

Psychiatric ROS: Denies symptoms of anxiety and depression. Negative for hallucinations, delusions, disturbed sleep, suicidal ideations, alcohol/substance use

Non-Psychiatric ROS: Denies any cardiovascular, respiratory, neurological, gastrointestinal, musculoskeletal, or genitourinary complaints

Objective Section

Physical Examination

General: Conscious patient, well groomed and kempt, in good general condition. He is not pale, not dehydrated, nit jaundiced, not cyanosed, not edematous, and has no lymphadenopathy.

Vital signs are as follows: Temperature 37.0 ◦C, HR 86 beats/minute, RR 22 breaths/minute, SPO2 100% on room air.

Neurological: GCS 15/15, oriented to time, place, and person, intact sensory and motor functions

Cardiovascular: normal precordium, S1, and S2 sounds present with no additional sound, apex palpated at 5th intercostal space, mid-clavicular line

Respiratory: Adequate bilateral chest expansion, bilateral resonance on percussion, bilateral equal air entry on auscultation

Diagnostic Results (Laboratory and Imaging)

Complete blood count: As a baseline hospital-entry test and to detect underlying anemia or deranged white blood cells

Urea and electrolytes: As a baseline hospital-entry test and to check for kidney function before putting the patient on any medication

Assessment

Mental State Examination

J is a 13-year-old White boy who appears to be his age. He is slim, tall, and well-groomed. He is slouching in his chair and does not maintain constant eye contact with the examiner. He is friendly, engaging, and cooperative, but sometimes rude and disrespectful when answering questions. His speech is loud, plentiful, and well-articulated, but he occasionally takes long pauses before answering questions.

He describes his mood as “not well” and “wants to go home,” and he appears tense. He has a broad, agitated affect that is appropriate. His thought process is logical and coherent, and his thought content is clear. He has no abnormalities in his perception. He is conscious, oriented to time, person, and place, and possesses intact short- and long-term memory. His judgment and abstraction are sound. He has grade 3 insight, which means he recognizes that his behaviors are abnormal but blames them on others and views his actions as retaliation when provoked.

Differential Diagnoses

Primary psychiatric diagnosis: Conduct Disorder

According to the DSM-5 diagnostic criteria, conduct disorder is diagnosed when there is a consistent pattern of behavior in which the fundamental rights of others and the age-appropriate social norms are violated (APA, 2013). In criteria A, there are 15 components, and the diagnosis needs just the existence of three out of the fifteen criteria present in the last twelve months, with at least one criterion present in the past 6 months.

Joe demonstrates aggression toward others, indicated by his inclination to physically assault his classmates, and engage in altercations with his siblings. Further, he deliberately damages others’ belongings, as evidenced by his activities of purposefully tearing particular pages of his classmates’ course books. Additionally, he has allegations of infractions of regulations at home and school.

At home, he fails to complete his domestic tasks, and at school, he is reported to be truant, bully his classmates, and has switched schools due to flagrant violations of school regulations. He has also been suspended from school twice in the previous three months for identical claims.

In criterion B, the disturbance generates substantial dysfunction in social, occupational, and other domains of functioning (APA, 2013), as indicated by J’s hardship in establishing new friends and trouble keeping existing ones, his discordance with his father, and bad performance at school. In criterion C, the person is under 18 years of age-J is 13 years old.

Antisocial Personality Disorder

Following his pervasive pattern of disregard for and violation of the rights of others, as evidenced by his physical fights and assaults, consistent irresponsibility at home and school, lack of remorse, and general failure to conform to societal age-appropriate norms, J may have an antisocial personality disorder. The DSM-5, on the other hand, adds an age cut-off, requiring the patient to be at least 18 years old for the diagnosis to be established.

Oppositional Defiant Disorder (ODD)

As demonstrated in J’s case, patients with ODD constantly engage in conflict with adults and authority figures such as parents and teachers. However, the actions of ODD are less extreme and do not entail aggressiveness against others or intentional damage of property, as seen in J, ruling out the diagnosis.

Treatment

Cognitive behavioral therapy: reshapes a child’s thinking (cognition), and improves problem-solving skills, anger management, moral reasoning, and impulse control (Nakao et al., 2021)

Parent-child interaction therapy: Educates parents on how to positively alter their child’s conduct at home (Niec, 2018). Parents grow to embrace their children’s differences and adopt strategies to handle them, distinct from other siblings.

Reflection

I have learned about the many impulse-control and conduct disorders, as well as their DSM-5 diagnostic criteria. I have also learned about the various presentations of the disorders, and I am confident in utilizing the DSM-5 to establish an accurate diagnosis while also ruling out potential differential diagnoses. As a junior, J is unable to make decisions about seeking care and treatment, so his parents must consent on his behalf, as evidenced by his mother’s haste to seek psychiatric consultation for him.

Regarding the socioeconomic determinants of health, J’s parents can afford care services thanks to their medical insurance. As health promotion measures, steady adult caregiving, good emotional support, and constant monitoring are all beneficial in assisting the patient to cohabit peacefully in all settings of society.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596
  • Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine15(1), 16. https://doi.org/10.1186/s13030-021-00219-w
  • Niec, L. N. (2018). Handbook of parent-child interaction therapy: Innovations and applications for research and practice (Larissa N. Niec, Ed.; 1st ed.). Springer International Publishing. https://books.google.at/books?id=xhh5DwAAQBAJ

Comprehensive Psychiatric Evaluation: Conduct Disorder 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.