Categories
Disruptive, Impulse Control and Conduct Disorders

What is Kleptomania?

Have you ever been in the checkout area of a grocery store and your eyes glance over to the stacks of candy and gum and you wonder to yourself, “Would anyone notice if I took one?” Thoughts like these are common and natural; while many people can quiet them in their minds after considering the consequences of getting caught, between 23.1 and 46.2 million people around the world are unable to resist these overwhelming impulses. Such individuals suffer from kleptomania, a type of disruptive behavior disorder characterized by compulsive stealing of items. It is important to note that these items could easily be invaluable or simply unnecessary to the person’s life. It has been found that two out of every three people diagnosed are women, and that onset normally occurs during the late teen to early adult years (Christianini, Conti, Hearst, Cordas, de Abreu, & Tavares, 2015). 

 

While it can be easy to dismiss those with this disorder and say people are being greedy or irresponsible, individuals with kleptomania actually report that their urges to steal are “out of character”, “uncontrollable”, or “wrong” (Blum, Odlaug, Redden, & Grant, 2018). Rather than a blameworthy desire to rebel, as it can easily be construed, this urge to steal is an uncontrollable impulse that the individuals wish they did not have. In addition, it is important to note that in the aftermath of a theft, it is very common for those with kleptomania to experience remorse and guilt (Blum et.al, 2018). That is to stress that these individuals do not take pride in their stealing and are often ashamed of their actions, but due to social stigma and legal repercussions almost never feel comfortable seeking professional help. Furthermore, people with kleptomania often suffer from severe emotional anguish, impaired quality of life, and are more likely to attempt suicide (Blum et. al, 2018). In addition, they tend to have serious legal problems and little to no self-esteem (Saluja, et al., 2014). One woman with kleptomania laments, “My entire life has been torment. Each day I worry about having the urges, and then I worry about being caught stealing. I can’t relax.” This woman’s experience demonstrates how truly agonizing it can be to suffer from kleptomania (Grant 2018).

 

The available research on kleptomania is severely limited due to the fact that it is such a rare disorder and obtaining substantial samples of individuals who suffer from it is quite difficult (Kim, Christianini, Aparecida, & Tavares, 2017). Another factor that further complicates research is that when an individual is diagnosed with kleptomania, it is very common for them to be diagnosed with an additional disorder, including substance abuse, mood disorders, and anxiety disorders.  kleptomania may even be directly associated with obsessive-compulsive disorder (OCD), as has been hypothesized by psychologists. Samples, however, have shown anywhere between 6.5% and 60% of individuals with kleptomania also having OCD (Saluja, Chan, & Dhaval, 2014). More research needs to be conducted concerning the combination of kleptomania with other kinds of disorders in order for us to fully understand how kleptomania affects an individual’s life and where specifically in the brain they are affected.

 

Treatment for kleptomania is still being developed, but as of now both psychotherapy and psychopharmacology are being utilized. One form of psychotherapy used is aversion therapy, which works by conditioning the person to associate their troublesome behavior with an unwanted stimulus, primarily electrical or chemical. More research must be conducted however, as a proper and standard treatment has not yet been established. 

 

Overall, it is difficult to establish a standard treatment for kleptomania, because like other disruptive behavior disorders, treatment depends on an individual’s unique temperament and experiences. There is no cure for this disorder, but it can be managed with ongoing therapy. People who are affected by kleptomania can explore the triggers to their compulsions and learn to manage them in more positive ways with the help of mental health professionals and strong support systems.

 

References

Blum, A. W., Odlaug, B. L., Redden, S. A., & Grant, J. E. (2018). Stealing behavior and impulsivity in individuals with kleptomania who have been arrested for shoplifting. Comprehensive Psychiatry, 80, 186–191. doi: 10.1016/j.comppsych.2017.10.002

Britannica, T. E. of E. (2018, November 23). Aversion therapy. Retrieved September 29, 2019, from https://www.britannica.com/science/aversion-therapy.

Christianini, A. R., Conti, M. A., Hearst, N., Cordas, T. A., Nabuco deAbreu, C., & Tavares, H. (2014, September 19). Treating Kleptomania: cross-cultural adaptation of the kleptomania Symptom Assessment Scale and assessment of an outpatient program. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0010440X14002697

 Grant, J. E. (2018, December 11). Kleptomania: Emerging therapies target mood, impulsive behavior. Retrieved from https://www.mdedge.com/psychiatry/article/59629/personality-disorders/kleptomania-emerging-therapies-target-mood-impulsive.

Kim, Hyoun S., Christianini, Aparecida Rangon, Hodgins, David C., & Tavares, Hermano. (2017). Impairments of kleptomania: what are they?. Brazilian Journal of Psychiatry, 39(3), 279-280. https://dx-doi-org.proxy.library.stonybrook.edu/10.1590/1516-4446-2017-2218 

Saluja, B., Chan, L. G., & Dhaval, D. (2014). Kleptomania: a case series. Singapore medical journal, 55(12), e207–e209. doi:10.11622/smedj.2014188

Categories
Disruptive, Impulse Control and Conduct Disorders

Comorbidity of Disruptive Behavior Disorders and ADHD

A child with ODD (Oppositional Defiant Disorder) or conduct disorder is more likely to be diagnosed with ADHD (Attention-Deficit/Hyperactivity Disorder) than a child with ADHD is to be diagnosed with ODD or conduct disorder. Research indicates that 50% of children with ADHD will either develop ODD or conduct disorder at some point in their development, which can explain why the percentage of adults and adolescents with ADHD and comorbid conduct disorder is higher than the percentage of children with ADHD or conduct disorder alone. About 40 % of individuals with ADHD have ODD, 27 % of children with ADHD have conduct disorder, 50 % of adolescents and 25 % of adults with ADHD have conduct disorder.

Attention Deficit Disorder, more commonly known as ADHD, is a struggle to live with on its own, but if a Disruptive Behavior Disorder gets tossed into the mix, it becomes even more complicated. Children with comorbid ADHD and conduct disorder engage in more delinquent behaviors than their peers and are at a higher risk of engaging in criminal behaviors in the future. They display “behavioral profiles similar to adult psychopaths” (Rapposelli, 2015). Those with comorbid ADHD and ODD express behaviors such as arguing, losing one’s temper, refusing to follow rules, blaming others for their behaviors, and deliberately annoying others. They are often angry, resentful, spiteful, and vindictive. In addition to this, youth with comorbid ADHD and ODD experience greater academic difficulties and rejection from their peers than youth with ADHD alone. There is an extremely strong relationship between academic failure, learning disabilities, and conduct disorder.

When there is a comorbidity between two disorders, it makes treating and living with both conditions complicated. A comorbidity of ADHD and ODD or ADHD and conduct disorder means that the quality of life will be very low due to the characteristics of both disorders. An individual with ADHD has the ability to learn information and skills, but they do not know how to use the information or implement those skills. This can cause them frustration and agitation. Throw in ODD, and you now have a person who is frustrated and agitated because their brain doesn’t let them use the information they have and they have a disregard for authority and rules. Conduct disorder involves extreme aggression, damaging property, and hurting other people and animals. When these symptoms are mixed with symptoms of ADHD, such as difficulty paying attention and the feelings associated with both these disorders, it becomes clear why these individuals have a low quality of life. But what can be done to help them?

Treatment options are available in the forms of therapy and medication, but emphasis is placed on preventative measures. Schools have psychologists and social workers who can help children with these disorders, but they cannot intervene at the early stages because there isn’t much research on the early signs of these comorbid disorders. Parents can be the first line of defense. Parents should be aware of their children’s behaviors, and if they notice their child acting overly aggressive, or having extreme difficulties in school, they should talk to a medical professional about it.

Early intervention after diagnosis is inherently important because the long term outcomes of children with comorbid ADHD and conduct disorder or ODD are vastly different from those with ADHD alone. One study followed two groups of children with ADHD. One group had comorbid ADHD and conduct disorder, the other group had ADHD only. At fourteen, 30% of the group with comorbid ADHD and conduct disorder had engaged in drug and alcohol abuse. There was no case of substance abuse in the other group. A similar study showed that one third of boys with ADHD and conduct disorder had committed multiple crimes as teenages whereas less than four percent of boys diagnosed with only ADHD had committed multiple crimes.

Research has also shown that early intervention can help individuals with comorbid ADHD and ODD or conduct disorder to have better academic performance, engage in social behaviors in a positive manner, and improve the overall quality of life. But in order to have early intervention, parents and schools need more resources and information about these disorders and their relationship to each other. Further research must be conducted in order to provide these resources to parents and schools.

References

Children and Adults with Attention-Deficit/Hyperactivity Disorder. (n.d.). Coexisting Conditions. Retrieved April 17, 2019, from https://chadd.org/about-adhd/coexisting-conditions/

Rabiner, D., Ph.D. (n.d.). Behavior Disorders that often co-occur with ADHD. Retrieved April 17, 2019, from http://www.helpforadd.com/co-occurring-disorders/

Rapposelli, D. (2015, September 9). Nipping ADHD and conduct disorder in the Bud. Retrieved April 17, 2019, from https://www.psychiatrictimes.com/adhd/nipping-adhd-and-conduct-disorder-bud

Skitterphoto. (n.d.). [Girl standing in field]. Retrieved April 17, 2019, from https://pixabay.com/photos/girl-bicycle-garden-people-outdoor-535251/

Turgay, A. (2005). Treatment of comorbidity in conduct disorder with attention-deficit hyperactivity disorder (ADHD). Retrieved April 17, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/16222912

Virginia Commission on Youth. (2017). Disruptive, Impulse-Control, and conduct disorders. Retrieved April 17, 2019, from http://vcoy.virginia.gov/documents/collection/021 Disruptive ODD2.pdf

Categories
Disruptive, Impulse Control and Conduct Disorders

Parents of Children with Conduct Disorder

“My son is a monster.”

“Everywhere we go we are the talk of the town. ‘The circus act.’”

“I need advice on how to keep our family [safe] when [our] son wakes up at 2 AM.”

Did you ever imagine being a parent and believing one of the above statements about your child? Parents of children with conduct disorder have. According to Mental Health America, “Conduct disorder is a repetitive and persistent pattern of behavior in children and adolescents in which the rights of others or basic social rules are violated.” Conduct disorder is characterized by aggressive behavior that can cause harm to other people or animals; non-aggressive but destructive behaviors such as arson or deliberate damage of property; deceitfulness or theft; and serious rule violations that usually require some sort of action to be taken.

Conductdisorders.com is an online support forum for parents of children with conduct disorder. User InTheMoment shares that their son, who is currently in a mental health facility, went around punching other children and the police had to get involved. User Lost in Parenthood shares that their son has been kicked out of various programs because of his behavior problems. They write that their son “curses like a sailor” even though neither parent uses language like that. User Pixie Dusted is a target for their son, he tells them he hates them. He also steals, hurts his siblings, and breaks things. Sail 24 talks about their 15-year-old son who has gotten in trouble with the police for stealing, has been evicted from boarding schools, and abuses drugs and alcohol. They talk about how different their life was when their child was not home, “…I could relax, we could breathe again…We did the things we always wanted to do all those times we’d say, ‘If only he was different.’”

Caring for a child with conduct disorder is extremely taxing on the parents. Feelings similar to those of the parents in the forum are common. However, this does not mean that the parents love their children any less. Support groups, online forums, and family therapy can be very helpful for parents. Forums and support groups lets these parents know that they aren’t alone. They can ask each other for advice or just talk about challenging moments they have had. Lost in Parenthood says that deep down, their son “is the sweetest boy a mom can ask for” and they “cry just seeing how people treat him because they do not know” of his disorder. These parents would do anything for their child, like every other parent. But parents are humans too; they have feelings like every one of us. What makes it even more difficult for the parents of children with conduct disorder is that ultimately they hold themselves responsible for their children’s actions and behaviors. They can feel like they are held captive by their child’s disorder, and it hinders them from living their own lives.

References:

In The Moment. (2019, March 31). I need advise on how to keep our family save when son wakes up at 2 AM. Retrieved April 1, 2019, from https://www.conductdisorders.com/community/threads/i-need-advise-on-how-to-keep-our-family-save-when-son-wakes-up-at-2-am.66156/

Lost in Parenthood. (2019, March 22). My son is a monster. Retrieved April 1, 2019, from https://www.conductdisorders.com/community/threads/my-son-is-a-monster.66127/

Mental Health America. (2013, October 14). Conduct Disorder. Retrieved April 1, 2019, from http://www.mentalhealthamerica.net/conditions/conduct-disorder

Pixie Dusted. (2019, March 23). What do I do? Retrieved April 1, 2019, from https://www.conductdisorders.com/community/threads/what-do-i-do.66132/

Quintana, I. (n.d.). Retrieved April 1, 2019, from http://www.citationmachine.net/bibliographies/433956074?new=true

Sail24. (2018, March 12). 15 year old with conduct disorder needs to leave our home. Retrieved April 1, 2019, from https://www.conductdisorders.com/community/threads/15-year-old-with-conduct-disorder-needs-to-leave-our-home.64966/

Categories
Disruptive, Impulse Control and Conduct Disorders

President Trump and His “Defiance Disorder”

“Oh my God, he just tweeted this,” said Reince Priebus, President Trump’s former chief of staff. The tweets in question essentially banned transgender individuals from serving in the military. Priebus was supposed to attend a meeting that very same day to discuss four different policy options instead of the total ban, but there was “no longer need for a meeting.” Incidents like this are not uncommon in President Trump’s administration. His erratic behavior has been noticed, not only by his aids and the media but also by the rest of the world. Questions about Trump’s mental and physical wellbeing are rampant. Many individuals and professionals have attempted to diagnose the president from afar. But are any of the diagnoses valid? These individuals are not President Trump’s official health care providers. President Trump’s aids are present in the White House and they have daily, firsthand observations of his behavior, but they aren’t trained healthcare professionals. On the other hand, healthcare professionals who have attempted to diagnose the president, don’t have a presence in the White House. All of these factors have impacts on the validity of these diagnoses.

The scene laid out above was recounted in Howard Kurtz’s book, Media Madness: Donald Trump, the Press, and the War over the Truth. Kurtz works for Fox News, and has worked for the Washington Post as well. In his book, he claims that “Trump’s aides even privately coined a term for Trump’s behavior—‘Defiance Disorder’” (Parker, 2018). According to an article published by the Washington Post, this phrase refers to the President’s “seeming compulsion to do whatever it is his advisers are most strongly urging against, leaving his team to handle the fallout.” This statement specifically refers to Oppositional Defiant Disorder, ODD, which is a childhood disorder characterized by negativistic, argumentative, and hostile behavior patterns (Sue, Sue, Sue, Sue, 2017). Furthermore, this disorder can only be diagnosed in children. While the validity of this term can be argued, evidence revealing that the president has made his staff feel like he would do whatever he wanted and they would be left to clean up his messes cannot.

“Kurtz describes White House aides waking up one Saturday morning in March, confused and ‘blindsided,’ to find that Trump had — without any evidence — accused former president Barack Obama on Twitter of wiretapping him during the campaign…‘Nobody in the White House quite knew what to do,’ Kurtz writes.” (Parker, 2018)

The president also allegedly replaced Reince Priebus with then-homeland security secretary John Kelly without informing him. Kurtz writes “Typically, Trump announced the decision without telling Priebus and without having made a formal offer to Kelly.” Kurtz is not the only one to write a book about the inner-workings of the Trump administration. In his book, Fire and Fury: Inside the Trump White House, journalist Michael Wolff claims, “people close to Donald Trump consider him a ‘moron’ who acts ‘like a child” (Frisk, 2018).

Conflicting and misleading statements from Trump and his top aides have fueled questions about the White House’s credibility. It has sowed mistrust and instability within the West Wing and left some congressional Republicans wondering if they have a “good faith negotiating partner in the president” (Pace, 2018). A former GOP leadership aide said that Republicans were having difficulty negotiating with White House officials because of “the president’s willingness to undermine his own team’s public and private assurances” (Pace, 2018). White House officials have been put in a predicament which is resulting in them urging lawmakers to ignore some of the president’s statements. Representative Charlie Dent of Pennsylvania has been openly critical about the president, stating “Disorder, chaos, instability, uncertainty, intemperate statements are not conservative virtues in my opinion” (Pace, 2018). The president seems comfortable changing facts that vary in scope from the size of his inaugural crowd to the scope of tax bills (Pace, 2018). Furthermore, “the president rarely appears to be embarrassed or ashamed about repeating statements that have been proven false” (Pace, 2018). This has a serious impact on the credibility of the Trump Administration. A survey from Quinnipiac University showed that fifty-four percent of Americans believe that Trump is not honest, and numerous reports corroborate these findings. When a majority of the public feels as though the President is not honest, it is no surprise that they doubt his well-being.

Concerns about the president’s health, both mental and physical, extend beyond the White House. President Trump’s personal doctor, Harold Bornstein, declared him “the healthiest individual ever elected to the presidency” (Strauss, Dickerman, Eizenstat, Kruse, 2017). Yet that didn’t stop Politico Magazine from claiming “no occupant of the Oval Office has evinced less interest in his own health” (Strauss, et al., 2017). The president seems to believe that exercise leads to health complications (Strauss, et al., 2017). Mental health professionals started a petition on change.org, stating:

“We…believe in our professional judgment that Donald Trump manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States. And we respectfully request he be removed from office, according to article 4 of the 25th amendment to the Constitution, which states that the president will be replaced if he is ‘unable to discharge the powers and duties of his office.’” (Gartner, n.d.)

A book has even been published titled The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. The president has been called out on his slurred speech, incoherence, and “increasingly erratic (and Freudian) tweets” (Levitz, 2018). Michael Wolff said “…inside of 30 minutes he’d repeat, word-for-word and expression-for-expression, the same three stories…” the repetitions would become more frequent, and Wolff claimed that Trump’s tweets were often a manifestation of these repetitions (Levitz, 2018). Journalist Eric Levitz argues that Wolff’s reporting establishes that Trump’s cognitive decline is affecting his daily functioning. Levitz writes that in response to President Trump’s tweet about “the size and potency of his nuclear button” one hundred mental-health professionals signed a statement claiming the president is “further unraveling” in ways that contribute to his “belligerent nuclear threats” (Levitz, 2018). They “urge those around him” and elected officials to take urgent action to “restrain his behavior” in order to diminish the potential of “nuclear catastrophe that endangers not only Korea and the United States but all of humankind” (Levitz, 2018).

Levitz argues that the president can be diagnosed from afar. The basis of this claim is that we have detailed accounts of the president’s behavior from people who work closely with him. He does not mention the possibility that these accounts are biased. They are not confidential conversations with a healthcare professional, in fact, they are the opposite. If the same people who have issued statements about the president’s health were to speak to a therapist, perhaps they would say something different. Generally, when a psychologist or psychiatrist makes a diagnosis, they have met with the individual being diagnosed and observed their behavior first-hand. They may meet with people who interact with the individual consistently, but those accounts alone are not usually the base for the diagnosis — they act more as supporting documents. How efficient is it to analyze someone using only testimonies from others?

Esquire magazine conducted a rather interesting “experiment” to determine whether the president’s behavior could be deemed “irascibly childish” (Fontana, 2017). They claim “His speeches and tweets are dominated by the kind of constant name-calling, defensive outbursts, mendacious gossip and repugnant innuendos usually overheard during schoolyard recess” (Fontana, 2017). They described “symptoms” to Dr. Megan Seltz, a clinical psychologist specializing in children with cognitive disorders. Dr. Seltz was under the impression that the patient whose symptoms were presented was an 8-year-old boy. Dr. Seltz’s opinion at the conclusion of the interview was that this hypothetical child is exhibiting signs of conduct disorder, but she could not diagnose him without a complete evaluation (Fontana, 2017). The source of all this controversy and diagnosis from afar seems to be that Trump publicly displays symptoms of mental disorder or neurological problems, and there is no office or position in place to evaluate his mental health.

The need for a role to determine a person’s mental capability to run a country is becoming increasingly more evident, as seen in Dr. James Hamblin’s article in The Atlantic. He writes, “A president could be actively hallucinating, threatening to launch a nuclear attack based on intelligence he had just obtained from David Bowie, and the medical community could be relegated to speculation from afar.” Factors such as age, and the magnitude of the weapons we now possess play a role on how stressful taking a seat in the oval office can be. The Constitution sets a lower limit for the age of the president, but there is no upper limit set. President Trump is seventy-two years old. Ronald Reagan was seventy-three when elected for his second term, making him the oldest president elected. Trump, if elected for a second term, will take his place.

With age, comes cognitive decline and a loss of brain matter. According to Dr. Hamblin, “After age 40, the brain decreases in volume by about 5 percent every decade” with the most apparent loss being in the frontal lobe, which controls speech and motor functioning. While this reasoning may not seem like enough to warrant the creation of a new role, it certainly raises the question of if there should be an upper age limitation as well. The magnitude of our weapons today is such that it is possible to “unilaterally destroy a continent, or the entire planet, with one quick decision” (Hamblin, 2018). Dr. Hamblin explains that the people responsible for actually launching missiles are tested three times a month on their ability to execute protocols. They are required to score at least 90 percent. He goes on to explain that ‘down-playing’ the president’s mental decline is not far from precedent. Franklin Delano Roosevelt hid his polio-induced paralysis from the public so as not to be seen as “weak or helpless.” It must be taken into consideration that the country’s circumstances during FDR’s presidency were immensely different. FDR became president during the height of the Great Depression, when 13 million Americans were unemployed. The country needed a strong leader to help boost morale. While unemployment rates are high today, they are not nearly at the same scale. It is also easier to hide paralysis than a mental illness. Hamblin also points out Trump’s speech patterns and how his ability to speak clearly and convey a message has declined over time. He mentions that the 25th Amendment assumes that “the president would be willing to undergo diagnostic testing and be forthcoming about any limitation,” and that this would be difficult with a person who has become known for “denying any hint of weakness or inability” (Hamblin, 2018). If a president had a mental disorder that impaired judgment, they also would not be likely to disclose information that might make them seem “weak.”

In 1994, President Jimmy Carter called for a system that could independently evaluate a president’s health and capacity to serve (Hamblin, 2018). “Carter called on ‘the medical community’ to take leadership in creating an objective, minimally biased process—to ‘awaken the public and political leaders of our nation to the importance of this problem’” (Hamblin, 2018). Twenty-five years later and we still haven’t taken action on this proposal. The questions surrounding President Trump’s mental health have spurred new proposals. Representative Jamie Raskin introduced a bill that would create an 11-member “presidential capacity” commission (Hamblin, 2018).

Dr. Hamblin claims that some may attempt to diagnose Trump from afar for the purpose of “political criticism” (Hamblin, 2018). According to him, this is dangerous for two reasons: (1) Labeling is “counterproductive” to the field because it increases the amount of stigma associated with psychiatric diagnosis, and (2) attributing Trump’s behavior to mental illness risks “devaluting mental illness” (Hamblin, 2018). It is a mental health professional’s job to be unbiased and non-judgemental. Hamblin suggests that a Carter-esque committee be formed, composed of “nonpartisan medical and psychological experts” that “need not have the power to unseat a president, undo a democratic election” (Hamblin, 2018). Hamblin recognizes that bias does play a role, but to a certain degree. And this degree isn’t large enough to render it “useless in assessing presidential capacity” (Hamblin, 2018).

The role of this proposed committee would be to issue a statement regarding the president’s fitness to execute the duties of the office he holds, the rest would be up to the people and their elected officials. This would attempt to provide the public with a transparent analysis of the person running the country. “The same cannot be said of the president’s cognitive processes,” Dr. Hamblin concludes, “We are left only with the shouts of experts from the sidelines, demeaning the profession and the presidency.”

References:

Fontana, K. (2017, October 11). How Do You Solve a Problem Child Like Donald Trump? Retrieved March 17, 2019, from https://www.esquire.com/news-politics/a49595/donald-trump-child-psychologist/

Frisk, A. (2018, January 22). Does Donald Trump have ‘defiance disorder?’: New book claims president’s aides think so. Retrieved March 16, 2019, from https://globalnews.ca/news/3979922/donald-trump-defiance-disorder-new-book-aides/

Gartner, J., Ph.D. (n.d.). Mental Health Professionals Declare Trump is Mentally Ill And Must Be Removed. Retrieved March 17, 2019, from Mental Health Professionals Declare Trump is Mentally Ill And Must Be Removed

Hamblin, J., Dr. (2018, January 03). Is Something Neurologically Wrong With Donald Trump? Retrieved March 17, 2019, from https://www.theatlantic.com/health/archive/2018/01/trump-cog-decline/548759/

Levitz, E. (2018, January 04). The President Is Mentally Unwell – and Everyone Around Him Knows It. Retrieved March 17, 2019, from http://nymag.com/intelligencer/2018/01/trump-is-mentally-unwell-and-everyone-around-him-knows-it.html?gtm=top

Pace, J. (2018, March 24). Trump’s impulses put White House credibility on the line. Retrieved March 17, 2019, from https://apnews.com/0a508c9559db4200aebe9d92c3c857ee

Parker, A. (2018, January 21). ‘Defiance Disorder’: Another new book describes chaos in Trump’s White House. Retrieved March 16, 2019, from https://www.washingtonpost.com/politics/defiance-disorder-another-new-book-portrays-chaos-in-trumps-white-house/2018/01/21/9362d160-febd-11e7-93f5-53a3a47824e8_story.html?noredirect=on&utm_term=.ca1502a70a99

Strauss, B., Dickerman, S., Eizenstat, S. E., & Kruse, M. (2017, July 18). Is the President Fit? Retrieved March 17, 2019, from https://www.politico.com/magazine/story/2017/07/18/is-the-president-fit-215385

Sue, D., Sue, D. W., Sue, D., & Sue, S. (2017). Essentials of Understanding Abnormal Behavior.

(3rd ed.). [Chegg]. Retrieved from https://ereader.chegg.com/#/books/9781305854703/

Categories
Disruptive, Impulse Control and Conduct Disorders

Intermittent Explosive Disorder

You’re at your favorite coffee shop on a beautiful morning. You’re happy; your morning has gone ideally, and it’s one of the best days you’ve had in a while. They call out your name to get your favorite drink, you take a large sip and…spit it all out.

Instantly, you are filled with a blinding rage—they’ve messed up your order!

You hurl it at the counter, cursing and screaming at everyone and everything around you.

You storm out, but by the time you get to your car, immense guilt has settled in.

You feel so bad, but you can’t face going back to apologize. You drive off and never return.

For someone with intermittent explosive disorder (IED), this happens regularly. Small things, like getting stuck in traffic on their way to work, can cause episodes of rage so intense, that the individual with this disorder can pose a threat to others or to themselves. Intermittent explosive disorder is a lesser-known mental disorder marked by episodes of unwarranted anger. It is commonly described as “flying into a rage for no reason” (Cleveland Clinic). Behavioral outbursts in an individual with intermittent explosive disorder are often disproportionate to the situation and often manifests itself in what seems like “adult temper tantrums” (Cleveland Clinic). Throwing objects, fighting for no reason, road rage, and domestic abuse are examples of intermittent explosive disorder. The outbursts typically last less than 30 minutes. After an outburst, an individual may feel a sense of relief – followed by regret and embarrassment.

IED often remains undiagnosed because of the nature of the disorder. People with this disorder are often labeled as “angry” and “impulsive”. The people around them don’t think to explore the underlying causes of the behaviors. Treatment options include cognitive behavioral therapy and medications, but they aren’t always effective. IED isn’t curable. These treatments attempt to make IED manageable by identifying triggers and teaching coping methods. However, the quality of life for many individuals who suffer from IED is still very low.

Carolina, age 31, who suffers from IED on a daily basis says, “I wish almost every day I could wake up and be someone else—a bubbly, happy, laughing girl who everyone likes and no one fears.”  She would see people shrug off incidents that would trigger her and feel both amazed and jealous. IED holds her back from the life she wants saying, “…I am dying for a family of my own and fear I won’t get it. All I’ve ever wanted was to be a mother and a wife. This is such a lonely life. Why am I this way?”

In her post on a support forum, she shared that two ex-boyfriends who were close to proposing left her because of her angry outbursts. One of them told her “he didn’t want to raise children in an environment where their mother would curse, shout and break things.”

She’s been fired for throwing a plant across the room at work. She also admits to calling her parents and yelling at them to the point where her mother starts crying. She feels regret and shame once the episodes pass, but she cannot control them:

“I was arrested in January for simple assault. I was in a verbally abusive relationship and my ex knew how to push my buttons. He one day went through my phone and said a bunch of crap to a guy friend of mine and then blocked him. When I found out the next day, I became enraged and physically beat my boyfriend to the point he called the police. Not only was I arrested but I was held in jail for two days…It was the lowest point of my life.” (Moon, C)

Carolina also shared that she has been taking medications and trying to manage her disorder for the past ten years. She says the medications will help calm her nerves with minor annoyances, such as road rage incidents. But she still struggles with IED every day, and she feels it is ruining her life.

Carolina’s feelings are not uncommon among those with IED. Many people feel like their disorder is ruining their lives and there isn’t much they can do about it. They worry about hurting those around them and themselves. Carolina is able to control some of her rage because she is receiving treatment. She understands that her disorder has a lot to do with her outbursts. However, someone who never received a diagnosis may be left wondering what is wrong with them. Caring for someone with IED is also a challenge. Support groups and classes are available to help caretakers understand what their loved ones need, and the best way to support them. IED is a relatively uncommon, often undiagnosed disorder. Parents assume their child is just being ‘difficult’ and don’t express their concerns to doctors or therapists. Expressing these concerns is crucial. Living with IED is not easy on the individual with the disorder or those around them, but living with undiagnosed, untreated IED is far worse.

References:

Cleveland Clinic. (n.d.). Intermittent Explosive Disorder Management and Treatment. Retrieved February 12, 2019, from https://my.clevelandclinic.org/health/diseases/17786-intermittent-explosive-disorder

Moon, C. (2016, July 20). IED is ruining my life: Intermittent Explosive Disorder Forum. Retrieved March 3, 2019, from https://www.psychforums.com/intermittent-explosive-disorder/topic184139.html

Staff. (2018, September 19). Intermittent explosive disorder. Retrieved March 3, 2019, from https://www.mayoclinic.org/diseases-conditions/intermittent-explosive-disorder/symptoms-causes/syc-20373921

Categories
Disruptive, Impulse Control and Conduct Disorders

Disruptive Behavior Disorders: What Are They?

Most of us have witnessed a toddler throwing a temper tantrum. For parents, toddler-hood entails endless screaming and crying. Toddlers behave in this way because they are experiencing emotions, but they do not have the tools to express them the way older children and adults do. As we age, we are supposed to outgrow these behaviors. We express our anger with words instead of fists pounding on the ground, we have the ability to explain why we are sad or frustrated. When a child fails to outgrow these behaviors, when they repeatedly lash out, are defiant and incapable of controlling their tempers, it can impair performance in school and cause serious family turmoil.

It’s easy to jump to the conclusion that a child who’s pushing or hitting or throwing tantrums is angry, defiant or hostile. But in many cases disruptive, even explosive behavior stems from anxiety or frustration that may not be apparent to parents or teachers. This “emotional dysregulation,” as clinicians refer to it, can reflect a number of underlying issues within broader umbrella of disruptive behavior disorders (DBDs). A major difference between DBDs and other mental health conditions is that with DBDs, the distress is focused outwards instead of inward. The dysregulated behavior is directed towards other people and property. This outward manifestation allows these disorders to be easily identified, however, the precise cause remains unknown. Risk factors include a family member with ADHD/Oppositional Defiant Disorder (ODD), depression or an anxiety disorder and environmental factors like stress in the home from divorce, separation, abuse, parental criminality or series of conflicts within the family. The disorders are also more likely to occur along with other conditions such as ADHD.

        Disruptive behavior, impulse control, and conduct disorders refer to a group of disorders that include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, kleptomania, and pyromania. An estimated 6 percent of children are affected by oppositional defiant disorder or conduct disorders, and each year an estimated 2.7 percent of children and adults in the U.S. are affected by intermittent explosive disorder. Conduct disorders tend to begin in childhood or adolescence and are more common in males than females. Kleptomania and pyromania are rare, affecting 1 percent or fewer of people in the U.S.

Disruptive behavior disorders are made up of two subtypes: Oppositional Defiant Disorder (ODD) and Conduct Disorder. ODD is the less severe of the two, and is more understood than Conduct Disorder. Both are the more common of all the DBDs. Children with ODD display a persistent pattern of angry outbursts, arguments and disobedience. While this behavior is usually directed at authority figures, like parents and teachers, siblings, classmates and other children can also turn into its target. Conduct disorder is a highly complex condition, and its causes aren’t fully understood. It can involve cruelty to animals and people, other violent behaviors and criminal activity.

Treatment is available for DBDs, most often in the form of therapy. Cognitive behavioral therapy is the most common for treating DBDs, although group therapy and family therapy has also proven quite successful especially in children. Medication may be given to treat symptoms of ODD. Parents and caregivers of children are often taught ways to cope with and manage their child’s disorder. It is important for anyone suffering from any of these disorders to get help because DBDs greatly affect quality of life. Left untreated, these disorders can cause major problems in all aspects of life, often leading to substance abuse disorders.

References

DeMaso, D. R., MD. (2011). Disruptive Behavior Disorders | Boston Children’s Hospital. Retrieved February 20, 2019, from http://www.childrenshospital.org/conditions-and-treatments/conditions/d/disruptive-behavior-disorders

Ehmke, R. (n.d.). What Is Oppositional Defiant Disorder? Retrieved February 12, 2019, from https://childmind.org/article/what-is-odd-oppositional-defiant-disorder/

Nicklaus Childrens Hospital. (n.d.). Disruptive Behavior Disorders. Retrieved February 12, 2019, from https://www.nicklauschildrens.org/conditions/disorders/disruptive-behavior-disorders

Parekh, R., M.D., M.P.H. (2018, January). What Are Disruptive, Impulse-Control and Conduct Disorders? Retrieved February 12, 2019, from https://www.psychiatry.org/patients-families/disruptive-impulse-control-and-conduct-disorders/what-are-disruptive-impulse-control-and-conduct-disorders 

Categories
Disruptive, Impulse Control and Conduct Disorders

The Blurred Line Between Impulse Conduct Disorder and Addiction

You’re sitting alone in your room, trying to combat the ennui you feel to be consuming you, and think to yourself, “Jason had texted me earlier if I wanted to shoot up some heroin. I know I shouldn’t… but what’s the harm in doing it one more time?” You find yourself calling your friend over; in the moments of waiting, you keep thinking to yourself how amazing the rush will feel when that needle spreads the drug inside you. You hear a knock on the door — it’s your friend. You give him a handshake, but not an affectionate one, just a habitual and mechanical one, getting it out of the way so the both of you could do what it is you really desire to do. He takes it out of the little plastic bag and disperses it onto your desk and asks you for a spoon and a lighter. You go to the kitchen to fetch the utensils, the whole time living in constant excitement of what you’re about to experience. You come back to your room with the utensils and give it to your friend, who puts the tan powdery substance onto a spoon, heats it up, and turns it into a bubbly liquid. Once this procedure is completed, your friend fills the syringe up with the liquid. He tries tying his arm up first, but you remind him that since he’s in the comfort of your home, you should get to go first. He groans and ties your arm up with a piece of cloth. Next thing you know, the needle pierces through your skin and you feel a rush of euphoria. In 3 hours, you start thinking to yourself, “Why did I do this? I don’t deserve to live,” or “I keep telling myself that I would practice self-control. Why do I keep failing?”

Impulse Control Disorders (ICDs) have been reported in the DSM-V as consisting of different manifestations. Examples of these manifestations include: Pyromania (the impulse to light things on fire), Kleptomania (the impulse to steal things), Intermittent Explosive Disorder (the impulse to have explosive outbursts of anger), trichotillomania (the impulse to pick at one’s skin), and Pathological Gambling, etc. In order to understand the distinction between people who have an ICD and people who have an OCD and avoid the common mistake of conflating the two, one must first understand the terms Egosyntonic and Egodystonic. Egosyntonic refers to pleasure seeking, or alleviating an urge which is self-perceived to be good. Egodystonic is the opposite, which refers to invasive thoughts and behaviors that conflict with
one’s actual needs.

The similarity between people who have an OCD and the people who have an ICD is that they both exhibit repetitive behaviors. However, one difference to make between the two is that someone with an ICD has an egosyntonic type of behavior. It often is paired with the urge to alleviate a desire and to obtain a rush from doing so. People with an OCD, on the other hand, have an egodystonic type of behavior. This is often paired with the obsession to act on a compulsive behavior, one which doesn’t necessarily induce pleasure in the person with an OCD. People with an ICD generally score high on measures of impulsivity like sensation-seeking criteria, while those who have an OCD score high on measures of harm avoidance. Due to this difference, people who have an ICD are more likely to also have a Substance Use Disorder (SUD).

Regardless of which comes first, the comorbidity of SUD paired with an ICD can further exacerbate the symptoms of latter to the former and vice versa. For example, a person who has an ICD is usually someone with a poor sense of self-control. Due to this lack of self-control, the likeliness to abuse drugs increases. According to Frontiers in Psychiatry, an estimated number of 20-50% of people who have ICDs also have problems with substance abuse.

An article published by HHS Public Access, states that there are multiple brain structures and chemicals involved with substance abuse. The lack of the D2 receptor (dopamine receptor) in certain structures of the brain is also shown to lead to impulsive choices. One structure is the amygdala, which is important in the assignment of emotional significance paired with social and individual contexts and needs. The Nucleus Accumbens links rewarding behaviors, which reinforce the habit of substance abuse, to the learning of said behaviors. Other structures include the orbitofrontal cortex (important for rational decision-making) and the striatum (low availability of D2 receptor in the striatum increases the self-administration of cocaine). All these structures work in conjunction with one another to facilitate our behaviors, according to the physiological rewards we receive from acting them out. The article also shows that these brain regions function abnormally in people with ICDs.

Genetics is also seen playing a role in ICDs. Family and twin epidemiologic studies have estimated that genetic contributions account for up to 60% of the variance in the risk for substance addictions. Similarly, the evidence is conclusive for the genetic contribution for people with Pathological Gambling (PG), a form of ICD. People who have ICDs may see their substance use as a form of self-medication, as mentioned above, and could further exacerbate the problem at hand. Some of them believe that no treatment is necessary. An article published by the NSDUH reports that in 2013, about 96 percent of people who needed special treatment for SUD didn’t think that treatment was necessary. Fewer than 20 percent of individuals fighting intermittent explosive disorder (IED), according to survey results published by Harvard Health, received specific treatment for their rage episodes.

Treatments for ICD include Randomized Control Trials. In these RCTs, one group takes a placebo, and the other group takes SSRIs. These tests have shown mixed results, with some RCTs working better than others. Altogether, the research shows that some individuals with ICDs benefit from SSRIs, while others do not. In society, the layman sees the behaviors of people with ICDs as self-inflicted choices. These trials show that this is not the case. 

As mentioned above, ICDs have a neurological basis that rewires the reward system of the brain in such a way that makes self-control difficult to maintain. This is not to say, however, that self-control is something unattainable; on the contrary, with a healthy and patient support group recovery can be possible. Where there is no help, just pain, and trauma, there is the need to alleviate it, and the slippery slope of addiction becomes a possibility. Therefore, it is important to seek help when it is needed.

References:

Judson A. Brewer, and Marc N. Potenza. The Neurobiology and Genetics of Impulse Control Disorders: Relationships to Drug Addictions Retrieved on September 15, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2222549/#R32

Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014 Retrieved on September 15, 2018 from https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

Treatment for intermittent explosive disorder. (2009). Mental Health Practice,12(5), 19-19. doi:10.7748/mhp.12.5.19.s28 Retrieved on September 15, 2018 from https://www.health.harvard.edu/newsletter_article/treating-intermittent-explosive-disorder

Liana Schreiber, Brian L. Odlaug, Jon E. Grant. Impulse Control Disorders: Updated Review of Clinical Characteristics and Pharmacological Management Retrieved on September 15, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3089999/