Chapter 10
Disruptive, Impulse-Control, and Conduct Disorders

The Disruptive, Impulse-Control, and Conduct Disorders chapter of the DSM-5 includes problems of self-control and represents the consolidation of all disorders related to emotional or behavioral dysregulation (APA, 2013a). Included in this chapter are oppositional defiant disorder (ODD), intermittent explosive disorder (IED), conduct disorder (CD), pyromania, and kleptomania. Counselors should note this is the first time disruptive, impulse-control, and conduct disorders have been clustered together in the DSM. Previously, ODD and CD were listed under disruptive disorders within the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter of the DSM-IV-TR. IED, CD, pyromania, and kleptomania were previously listed under the Impulse Control Disorders Not Elsewhere Classified chapter. The overuse of the NOS title, poorly defined diagnostic criteria, limited empirical evidence, and questionable comorbidity prompted significant critiques (Coccaro, 2012; Grant, Levine, Kim, & Potenza, 2005; Pardini, Frick, & Moffitt, 2010; Paris, 2013). Some critics called disorders categorized in the Impulse-Control Not Elsewhere Classified chapter in the DSM-IV-TR “a number of leftovers” (Morrison, 2006, p. 440) and “orphan[s] left over from previous manuals” (Paris, 2013, p. 150).

Note

Pathological gambling, now called gambling disorder, and trichotillomania, now called trichotillomania (hair-pulling disorder), were previously included within the Impulse Control Disorders Not Elsewhere Classified chapter of the DSM-IV-TR. These disorders have been moved in the DSM-5 to chapters that more appropriately match diagnostic criteria and processes for these disorders. See DSM-5 chapters Substance-Related and Addictive Disorders for information regarding gambling disorder and Obsessive-Compulsive and Related Disorders for information regarding trichotillomania (hair-pulling disorder).

Characteristics of disruptive, impulse-control, and conduct disorders are aggressive or self-destructive behavior, destruction of property, conflict with authority figures, disregard for personal or social norms, and persistent outbursts of anger disproportionate to the situation (APA, 2013a; Grant et al., 2005). Whereas the urge to engage in a behavior that harms oneself or others is common to many mental health concerns (e.g., substance-related and additive disorders), those listed in this diagnostic category include behaviors that either violate the rights of others or diverge significantly from societal norms (APA, 2013a; Coccaro, 2012).

Two disorders within this chapter, pyromania and kleptomania, are characterized by “tension and release” behavior (Morison, 2006, p. 439). Similar to obsessive-compulsive and related disorders, clients feel a sense of affective arousal (i.e., tension) before engaging in the antisocial behavior of fire setting (pyromania) or theft (kleptomania). What differentiates these disorders from obsessive-compulsive related disorders is that individuals with impulse-control disorders are generally sensation-seeking, whereas individuals with obsessive-compulsive related disorders have risk-avoidant behavior such as constantly checking and rechecking locks, repetitive hand washing, or picking at hair and skin (see Chapter 6 for more information; Grant, 2006).

Note

For obsessive-compulsive and related disorders, approximately 70% of individuals in the United States, at some point in their lives, exhibit obsessive-compulsive symptoms (den Braber et al., 2008). The same is true for disruptive, impulse-control, and conduct disorders in that nearly all children and adolescents experience symptoms of defiant, rule-breaking, and disobedient behavior at some point in their development. However, the regularity, pervasiveness, and impairment experienced by some individuals exceed normative behavior for their age, gender, and culture (APA, 2013a).

Whereas the underlying cause varies greatly from disorder to disorder, all diagnoses in this chapter share the common characteristic of problems with emotional or behavioral regulation (APA, 2013a). Moreover, all disorders in this chapter are marked by significant impairment associated with symptoms. These disorders are more common in males than females, and age of first onset tends to be in childhood or adolescence (APA, 2013a; Paris, 2013). It is considered rare for disruptive behavior disorders to emerge in adulthood. There is a developmental relationship between ODD and CD, in that individuals diagnosed with CD in preadolescence typically have been diagnosed with ODD previously (Burke, Waidman, & Lahey, 2010; Merikangas, Nakamura, & Kessler, 2009). However, roughly two thirds of children diagnosed with ODD will no longer meet diagnostic criteria after 3 years (Steiner & Remsing, 2007). Risk indicators for CD are earlier onset of ODD, as research indicates the likelihood of ODD progressing to CD is 3 times more likely. Additionally, counselors should closely monitor clients with CD for antisocial personality disorder (ASPD) because 40% of individuals diagnosed with CD eventually meet the criteria for ASPD (Steiner & Remsing, 2007). However, this does not mean that most children with ODD eventually develop CD. Although these individuals are at risk for various mental health concerns, particularly depressive or anxiety disorders, they are not preordained to be diagnosed with CD (APA, 2013a; de Ancos & Ascaso, 2011; Kolko & Pardini, 2010; Nock, Kazdin, Hiripi, & Kessler, 2007; Pardini et al., 2010).

Major Changes From DSM-IV-TR to DSM-5

As noted previously, the new Disruptive, Impulse-Control, and Conduct Disorders chapter includes a number of disorders previously categorized in the Impulse Control Disorders Not Elsewhere Classified and the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapters of the DSM-IV-TR. As with all diagnostic categories within the DSM-5, the Disruptive, Impulse-Control, and Conduct Disorders chapter has criteria for other specified disruptive, impulse-control, and conduct disorder and unspecified disruptive, impulse-control, and conduct disorder. Although ODD and CD have been included in diagnostic nosology since the second edition of the DSM, conceptualizations of these disorders have been modified considerably from edition to edition (Pardini et al., 2010). Although the DSM-5 did not have any significant changes to these diagnoses, this is the first time all mental health disorders marked by disruptive behavior and impulse-control problems, including those which go against social norms (i.e., pyromania and kleptomania), have been clustered together in the same section.

Categorizing these disorders according to common phenomenology has both clinical utility and heuristic value. Because many of these disorders are similar enough to be grouped together but distinct enough to subsist as separate disorders, counselors can more easily distinguish them from one another. For example, including IED and ODD in the same diagnostic classification allows counselors to more easily identify marked differences between these diagnoses. Second, because these disorders are grouped according to symptomatology, researchers can more easily create testable theoretical explanations for disruptive, impulse-control, and conduct-based disorders.

Aside from being an entirely new chapter, there are relatively few changes to the disorders within this section. There have been no changes to diagnostic criteria for CD, but an additional specifier of with limited prosocial emotions has been added (APA, 2013a). This is indicated when numerous sources (i.e., parents, teachers, extended family members, peers) report a lack of remorse or guilt, callous behavior, indifference to poor performance, or a lack of emotional expression or superficial affect (APA, 2013a). Placement of CD follows ODD and IED, thus reflecting the developmental relationship between ODD and CD (Paris, 2013).

ODD includes a new clustering of symptoms and new language to further clarify frequency and persistence of observed behavior. Whereas the DSM-IV-TR did not allow one to diagnose ODD if CD was present, the DSM-5 has no such restriction. Consistent with the DSM-5's focus on dimensional rather than categorical assessment, ODD also includes new severity specifiers.

Note

The questionable “rule” that individuals diagnosed with CD cannot be diagnosed with ODD has been removed in the DSM-5. Whereas ODD symptoms are undoubtedly associated with CD symptoms over time, individuals with angry or irritable symptoms are more likely to develop emotional disorders such as depressive, anxiety, or substance use disorders. Likewise, individuals with headstrong symptoms (i.e., argues with authority figures) are likely to be diagnosed with ADHD. On the other hand, spiteful or hurtful behavior such as aggression or callousness has been found to be most strongly associated with CD.

Finally, IED includes three new criteria for consideration: The recurrent aggressive outbursts must be impulsive and not premeditated, must cause marked distress in occupational or interpersonal functioning, and may not be diagnosed until after the age of 6 (APA, 2013a). As mentioned, counselors should note that pathological gambling—renamed gambling disorder—previously included in the Impulse Control Disorders Not Elsewhere Classified chapter of the DSM-IV-TR has been moved to the Substance-Related and Addictive Disorders chapter, and trichotillomania (hair-pulling disorder) has been moved to the Obsessive-Compulsive and Related Disorders chapter.

Differential Diagnosis

It is not uncommon for individuals diagnosed with ODD or CD to also exhibit symptoms of ADHD (APA, 2013a; Paris, 2013). ASPD, because of its close association with CD, is cross-listed in this chapter as well as the Personality Disorders chapter. Symptoms of disruptive, impulse-control, and conduct disorders have commonly been misdiagnosed as pediatric bipolar disorder. Given the addition of DMDD to the DSM-5, counselors are advised to consider carefully whether temper outbursts are related to an underlying mood concern such as DMDD or behavior disorders such as IED, ODD, and CD. Although rare, counselors should carefully consider the nurturing environment of any child diagnosed with ODD to rule out RAD (Widom, Czaja, & Paris, 2009).

Disorders in this chapter have high comorbidity with substance use disorders as well as depressive disorders and anxiety disorders (de Ancos & Ascaso, 2011; Nock et al., 2007). Aside from ADHD, disruptive behavior disorders are the most common reason for mental health referrals for children and adolescents (Merikangas et al., 2009). Counselors can differentiate disruptive, impulse-control, and conduct disorders from other disorders by attending to key features of each disorder. For example, IED is related to impaired ability to control one's emotions, ODD tends to be related to one's attitude toward others, and CD may be more intentional and is related to engagement in behavior that violates the rights of others. Whereas ADHD and substance use disorders involve difficulties with impulse management, this is not the primary feature of these other disorders (Ploskin, 2007).

Etiology and Treatment

The literature is quite abundant with regard to the etiological development of disruptive, impulse-control, and conduct disorders. Researchers have identified biopsychosocial (Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001), environmental (Burke, Loeber, & Birmaher, 2002; Burt, Krueger, McGue, & Iacono, 2001), genetic (Eley, Lichtenstein, & Moffitt, 2003; Waldman & Rhee, 2002), emotional (Morrell & Murray, 2003), and familial (Frick et al., 1992; Joussemet et al., 2008) factors. However, despite being grouped together diagnostically, separate pathways for the development of each disorder are found within the literature. Little genetic evidence has emerged as a causal factor for disruptive behavior disorders (Jacobson, Prescott, & Kendler, 2002). Whereas genetic links to ADHD are quite abundant (A. S. Rowland, Lesesne, & Abramowitz, 2002)—and resulted in its controversial placement within the Neurodevelopmental Disorders chapter of the DSM-5—biological contributions for disruptive or conduct disorders appear to be relatively small. Likewise, psychobiological studies for these disorders are also inconclusive (Hinshaw & Lee, 2003).

Most researchers have emphasized environmental origins for disruptive behaviors (Burke et al., 2002; Burt et al., 2001; Coie & Dodge, 1998; Hinshaw & Lee, 2003). Familial psychopathology, caregiver substance abuse, caregiver criminality, modeling of aggression, low socioeconomic status, family dysfunction, poor parent–child interactions, and abuse and neglect have been identified as high risk factors for the development of these disorders (Coie & Dodge, 1998; Frick et al., 1992; Joussemet et al., 2008; SAMHSA, 2011b). Other associated factors include cognitive deficits (Moffitt & Lynam, 1994), difficulties in social–cognitive information processing (Crick & Dodge, 1994), and peer rejection (Coie & Dodge, 1998). From a neurological perspective, brain structures within the limbic system (associated with emotions and the formation of memories) and the frontal lobe (linked to planning and controlling impulses) have been connected to disruptive and conduct disorders (Burke et al., 2002; Ploskin, 2007).

There is evidence that neurological irregularities and imbalance of testosterone may play a role in the formulation of disruptive behavioral and impulse-control disorders. In one study, children diagnosed with ODD and CD who had lower levels of testosterone pretreatment were 4 times more likely to respond to treatment and maintain gains compared with those with high levels of testosterone (Shenk et al., 2012). Although controversial, studies that indicate women are predisposed to less aggressive types of impulse-control disorders (i.e., kleptomania) and men to more violent and aggressive types (i.e., pyromania and IED) support this evidence. Researchers have also found connections between certain types of seizure disorders and violent impulsive behaviors (Brower & Price, 2001).

Treatment for these disorders is complex because of the heterogeneity of risk factors and etiological origins. Evidence-based treatments for disruptive behavior disorders tend to fall into several primary categories: parent/family interventions, CBT, and psychopharmacological treatment (Clark & Jerrott, 2012; Eyberg, Nelson, & Boggs, 2008; SAMHSA, 2011b). A systematic review of research regarding evidence-based psychosocial treatments for children and adolescents with disruptive behavioral disorders resulted in identification of 15 potentially efficacious treatments and one well-established treatment (Eyberg et al., 2008). Typically, parent training approaches include fostering positive time between parent and child, modeling of behaviors, introducing rewards and consequences, and teaching coping skills for dealing with difficult behavior. Through CBT, counselors can help clients modify cognitive distortions responsible for the disruptive behavior. This approach helps children and adolescents develop problem-solving skills to improve inhibition, recognize social problems and triggers for disruptive behavior, and pursue more effective alternatives. Parental and psychopharmaceutical interventions are also common (Weyandt, Verdi, & Swentosky, 2010).

Eyberg et al. (2008) concluded that parent training should be a primary approach for young children, noting that counselors may use direct interventions with other children who have the capacity to benefit from the often cognitive–behavioral strategies used in group and individual interventions. For cases in which behavior is more chronic or severe, counselors should consider multicomponent treatment approaches that involve parents, teachers, and mental health providers as change agents. Counselors who are interested in a review of evidence-based treatments for disruptive behavior disorders should refer to the SAMHSA's (2011a) Interventions for Disruptive Behavior Disorders Kit or Eyberg et al.'s (2008) review.

Psychopharmacological treatments have been found to be effective for pyromania (Parks et al., 2005) and kleptomania (Koran, Bodnik, & Dannon, 2010). Although no treatment approaches have conclusively been determined as effective, many varied approaches, such as CBT and dialectical behavior therapy (DBT), have been found helpful (Koran et al., 2010). Verheul et al. (2003) cited DBT as “the treatment of choice for patients with severe, life-threatening impulse-control disorders” (p. 139). Other treatment options include training for parents; behavioral therapies that focus on corrective consequences, contracting, and token reinforcement; problem-solving skills training; relaxation techniques to reduce the “urge” to engage in a behavior; overt sensitization; and specific psychoeducation such as fire safety/prevention and knowledge of legal consequences for shoplifting or theft (Koran et al., 2010). Individual and family therapy have also been found helpful.

Implications for Counselors

Counselors across settings will work with clients who engage in behaviors considered deviant and problematic to others. Kleptomania and pyromania are rare, however, with a prevalence of 0.3% to 0.6% in the general population for kleptomania, and among persons within the criminal justice system for fire setting, only 3.3% met the diagnostic criteria for pyromania (APA, 2013a). Disruptive behavior disorders such as ODD and CD are quite common within the general population (American Academy of Child & Adolescent Psychiatry, 2011; SAMHSA, 2011b). Unique challenges in working with individuals with disruptive behaviors include compounded dynamics of working with children and adolescents in general, dynamics of working with offender or nonvoluntary populations, family engagement, assessment considerations, and interdisciplinary collaboration.

Few counselors will argue that the development of a strong therapeutic relationship is essential for counseling success. Counselors may struggle to develop relationships with adolescents in general, and this struggle may be compounded given that the very nature of disruptive behavior and impulse-control disorders means that individuals are most likely engaging in deviant behavior, have difficulty considering others' perspectives, and will not present to counseling voluntarily. Like many offender populations, most youth with disruptive behavior disorders will be mandated into counseling because they have engaged in behavior that adults in their lives find problematic. In many cases, these youth may have difficult and even traumatic relationships with other adults (SAMHSA, 2011b); it would only be normal that they may have difficulty trusting and connecting with other adults. It is critical that counselors consider methods for developing nonjudgmental relationships that do not unintentionally condone defiant or oppositional behavior.

Abuse, neglect, and other unhealthy family dynamics are risk factors for disruptive behavior disorders (SAMHSA, 2011b). Counselors would be wise to consider carefully whether an individual's behavioral difficulties are the result of difficult or even dangerous conditions within the home. At the same time, counselors must take care not to jump to conclusions, pathologize, or otherwise blame caregivers of children with disruptive behavior disorders for their children's difficulty. Certainly, family engagement is difficult yet critical to treatment success (Gopalan et al., 2010), and it is the foundation of nearly all evidence-based treatments for these disorders.

Developmental pathways between ADHD, ODD, CD, ASPD, and adult criminal behavior (Burke et al., 2010) and evidence of striking comorbidity with other disorders (de Ancos & Ascaso, 2011; Nock et al., 2007) make accurate assessment of individuals with disruptive behavior disorders critical. Counselors should consider barriers to accurate assessment, including the likelihood of client underreporting or denying deviant behaviors in manners consistent with those experienced by individuals with substance use disorders. In addition, we urge counselors to look beyond difficult behaviors to consider possible underlying concerns related to learning, mood, and anxiety. Indeed, the National Comorbidity Survey Replication indicated that over 90% of individuals diagnosed with ODD met criteria for another mood, anxiety, impulse-control, and/or substance use disorders (Nock et al., 2007).

As noted previously, ADHD frequently occurs alongside disruptive behavior disorders (Pardini & Fite, 2010), and disruptive behavior at school may also be a result of unrecognized learning difficulties or frustrations. Careful assessment prior to treatment can help counselors and families understand children's developmental, academic, and social needs; co-occurring mental health concerns; barriers to treatment; and treatment preferences (Eyberg et al., 2008). Once the disruptive behaviors are identified, counselors can select from a range of evidence-based treatments to work with both child and family.

Finally, counselors who work with individuals who present with disruptive, impulse-control, and conduct disorders should be prepared to collaborate with professionals in other disciplines. Individuals may present to counseling with a court mandate, with the hopes of reducing legal involvement, or when having substantial problems within school or community settings. Thus, counselors may find themselves members of interdisciplinary treatment teams or in positions to advocate for a child within his or her system.

To help readers better understand changes from the DSM-IV-TR to the DSM-5, the rest of this chapter outlines each disorder within the Disruptive, Impulse-Control, and Conduct Disorders chapter of the DSM-5. As with other chapters in this text, coverage for each disorder includes highlights of key changes, essential features, and special considerations for counselors. Readers should refer to the DSM-5 to develop a full understanding of diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder.

313.81 Oppositional Defiant Disorder (F91.3)

Everything is an argument, and not just with me. Michael fights with his teachers, his mom, and his siblings. For at least a year now, he has been angry, irritable, and restless. He refuses to follow any rules and seems to deliberately defy his mother and me. Honestly, it is his behavior toward our 8-year-old neighbor Max that worries me the most. Sometimes he just seems cruel, even malicious toward him. —Everett (Michael's dad)

Essential Features

Oppositional defiant disorder (ODD) is characterized by a repetitive pattern of defiant, disobedient, hostile, and negative behavior toward others (Pardini et al., 2010). This disorder consists of three categories of behavior: (a) anger and irritability, (b) quarrelsome and defiant behavior, and (c) vindictiveness (APA, 2013a). Within any of these three categories, at least four symptoms (see diagnostic Criterion A for ODD in the DSM-5) must be present for at least 6 months.

Special Considerations

According to the DSM-5, prevalence of ODD within the general population is 3.3%; however, the prevalence has been estimated to be as high as 16% in the general population (American Academy of Child & Adolescent Psychiatry, 2011; SAMHSA, 2011b). Results of the National Comorbidity Survey Replication indicated a 10.4% lifetime prevalence of ODD (Nock et al., 2007). Although many studies indicate ODD is more prevalent in boys, especially when diagnosed prior to adolescence (APA, 2013a), some critics argue that existing criteria for ODD is biased against girls (Pardini et al., 2010; Paris, 2013). Nock et al. (2007) reported lifetime prevalence of 11.2% for males and 9.2% for females. New onset of ODD symptoms may begin as early as the preschool years and is rare after early adolescence. Boys presented with more functional impairments in the school and community and were more likely to be expelled from school and to have police involvement compared with girls. Parental reports indicated boys had more difficulty with comorbid ADHD and other attention problems. In contrast, girls with ODD were more likely to report difficulty with mood, self-harm, and thinking; reports from caregivers indicated more comorbid problems with depression, generalized anxiety, and somatic concerns.

Individuals diagnosed with ODD typically are unaware that their attitude and behavior are oppositional (APA, 2013a). Behavior becomes a repetitive pattern, often leading the individual to have significant problems interacting with others. It is not surprising that ODD is more common in families in which child care is interrupted and negligent, caregivers are inattentive, and otherwise harmful child-rearing practices are common (APA, 2013a).

When diagnosing any type of disruptive behavior, counselors need to tread carefully because these diagnoses tend to describe a broad range of behavioral problems, many of which may be developmentally appropriate. When assessing for ODD, counselors should inquire with multiple parties about argumentative behavior. Counselors might start by asking whether the individual gets into power struggles with authority figures and requesting information about the different settings and scenarios in which the behavior occurs. It is not uncommon for ODD to be exclusively present at home or school; when symptoms are present within more than one setting, counselors should consider the behavior to be more severe. Symptoms that occur in a specific setting or circumstance may be normal, developmental, or adaptive responses to difficult environments. Whereas ODD is typically thought of as a developmental antecedent to CD (APA, 2000), counselors need to be aware that not all adolescents diagnosed with ODD will go on to develop CD (Kolko & Pardini, 2010).

When diagnosing ODD, counselors must be sure that behaviors used to make the diagnosis are not age appropriate for the client's developmental stage or normative for the client's gender or culture. For example, it is not unusual for children to display independence-seeking behavior that may be considered disruptive or argumentative (e.g., weekly temper tantrums; APA, 2013a). However, if behavior is persistent, lasts at least 6 months, and is clearly disruptive toward others, counselors may need to consider a diagnosis of ODD. For example, an occasional temper tantrum may not be problematic; however, ODD may be present when tantrums occur alongside many other symptoms and result in educational and social impairment (e.g., being asked to leave a playgroup, suspension from school). Finally, in terms of cultural considerations, manifestations of the disorder have been found to be consistent across cultural backgrounds (APA, 2013a). Still, counselors are advised to consider carefully whether what they perceive to be oppositional behaviors could be actually adaptive and even normative communication patterns within a client's socioeconomic context.

Differential Diagnosis

A diagnosis of ODD cannot be given if an individual meets criteria for DMDD (APA, 2013a). If criteria for DMDD are met, it is assumed that the mood disorder accounts for the child's oppositional behavior and attitudes. Although ODD may be diagnosed alongside CD, ADHD, or IED, it is essential that counselors consider carefully whether symptoms meet criteria for one or both disorders. For example, minor rule-breaking associated with ODD may be more about pushing limits and irritating adults, whereas law-breaking behaviors associated with CD may result in significant injury to individuals or damage to property. As noted in the DSM-5, anger in ODD tends to be generalized, whereas anger in IED is characterized by aggression to others. Given that ADHD is commonly diagnosed alongside ODD, counselors should also carefully consider comorbidity with ADHD. Among individuals diagnosed with ODD, 29.0% also met criteria for IED, 35.0% met criteria for ADHD, and 42.3% met criteria for CD (Nock et al., 2007). Finally, it is important to note that children and adolescents may manifest mood concerns with irritability and agitation rather than sadness. Thus, counselors should consider the possibility of coexisting or superseding depressive disorders and bipolar disorders. This is particularly important because individuals diagnosed with ODD had a 45.8% comorbidity with mood disorders, 62.3% comorbidity with anxiety disorders, and 47.2% comorbidity with substance use disorders (Nock et al., 2007).

Coding, Recording, and Specifiers

There is only one diagnostic code for ODD: 313.81 (F91.3). Counselors must indicate current severity of mild, moderate, or severe. There are no codes associated with these specifiers.

Note

If symptoms are present in more than one setting (e.g., school and home), counselors may want to indicate a severity specifier of moderate or severe.

312.34 Intermittent Explosive Disorder (F63.81)

I was 23 years old when my best friend from high school told me she was done with our friendship. She said my temper was out of control and she never knew when I was going to “fly off the handle.” I thought she was being melodramatic, but 6 months later I had three separate charges for assault. I tried to explain to my lawyer how all of a sudden I just feel rage. Someone would piss me off and bam . . . I would have to hit them or throw something. — Raquel

Essential Features

Intermittent explosive disorder (IED) is characterized by an individual's inability to control his or her response to a stressor or frustration. IED results in excessive, unplanned verbal or physical outbursts among individuals at least 6 years of age. According to the DSM-5, less severe outbursts must occur at least twice weekly over a period of 3 months; an individual may also qualify for IED if he or she engages in at least three episodes that resulted in damage to property or injury to others over the period of a year (APA, 2013a).

Special Considerations

Counselors should be aware that some researchers believe little empirical evidence exists for IED (Paris, 2013), and diagnostic criteria for IED have been poorly operationalized (Coccaro, 2012). Coccaro (2012) reported that new DSM-5 criteria for IED result in better identification of individuals who have concerns with aggression, impulsivity, family risk, and neurobiological markers related to aggression. An epidemiological study regarding IED revealed that, statistically speaking, a categorical or taxonic definition of IED fits data better than a dimensional assessment, thus suggesting that individuals with aggression associated with IED are qualitatively different from individuals with nonpathological levels of aggression (Ahmed, Green, McCloskey, & Berman, 2010). In Ahmed et al.'s (2010) study, those meeting criteria for IED-related anger compared with those with non-IED anger were, respectively, younger at age of onset (14.23 years vs. 17.68 years), more likely to be male (57.22% vs. 41.88%), more likely to seek treatment (28.34% vs. 0.50%), and more likely to report a family history of anger attacks (71.17% vs. 3.46%). They also reported more anger episodes not due to substance use (100% vs. 43.48%), physical illness (63.74% vs. 39.39%), or sadness (56.45% vs. 39.63%). The DSM-5 includes a notation that IED is more common in individuals who are younger and have lower levels of education.

Some researchers have claimed a lifetime prevalence of 7% among the general U.S. population, but critics posited that this number is inflated given the ambiguous criteria of IED and the considerable challenges of conceptualizing the disorder (Kessler et al., 2008). The DSM-5 reports a 1-year prevalence of 2.7% (APA, 2013a). Ahmed et al. (2010) reported a prevalence rate of 5.5% and noted that stringent DSM criteria may result in underidentification of individuals with IED.

Counselors should also carefully consider the use of this diagnosis in forensic settings when actions of individuals have not been premeditated (Paris, 2013). A good question counselors can ask clients is, “Do you ever become hostile or destructive when you get angry?” Follow-up questions regarding the nature and frequency of anger episodes will help counselors assess for the possibility of IED-related aggression.

Differential Diagnosis

IED includes recurrent behavioral outbursts or disruptions. When assessing for this disorder, counselors would be wise to consider a number of other disorders in which behavioral outbursts are present. These may include disorders within this chapter such as ODD and CD, as well as disorders such as ADHD, DMDD, bipolar and related disorders, and personality disorders in which individuals experience difficulty with impulse control. It is also possible that one experiences aggressive outbursts only when under the influence of a substance; in this case, substance use disorder or substance intoxication may better account for the symptoms. Although counselors should not diagnose IED if another disorder better explains the concern, the DSM-5 includes a notation that IED can be diagnosed alongside other disorders if “recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention” (APA, 2013a, p. 466).

Coding, Recording, and Specifiers

There is only one diagnostic code for IED: 312.34 (F63.81), and there is only one specifier for this disorder. Counselors must indicate current severity of mild, moderate, or severe. There are no codes associated with these specifiers.

312.8_ Conduct Disorder (F91._)

Jessica was arrested for destruction of property and stealing 4 weeks ago. She and some friends went into a convenience store after it had closed and bashed in the windows, destroyed all shelving, and took everything they could. This isn't the first time either. I found out later she did this at another convenience store and frequently shoplifts at Target and other large stores. Jessica has been charged only once for destruction of property, but she just blamed it on her friends. She doesn't seem to even care about what she is doing. She shows no remorse, even when she has seen her friends get into serious trouble. She just acts like she doesn't care. Honestly, I am afraid to ask her about anything else. I know there is more. For years she has been skipping school, getting into fights, stealing my car, and, although no one has directly accused her, I know she hurt our neighbor's rabbit which used to live in a shed in their backyard. —AJ (Jessica's father)

Essential Features

Conduct disorder (CD) is characterized by “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” (APA, 2013a, p. 469). The DSM-5 operationalizes this as at least three symptoms over the course of 1 year; because CD is most common among youth, at least one symptom has to be present in the most recent 6 months. Symptoms fall into four clusters involving aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. See Criterion A within the DSM-5 for specific examples of CD symptoms.

Special Considerations

APA (2013a) identified the 1-year prevalence rate of CD as 2% to 10%, consistent across diverse populations and higher among males than females. In a review of research regarding CD risk factors and characteristics, Murray and Farrington (2010) found that 6% to 16% of adolescent boys and 2% to 9% of adolescent girls met criteria for CD at any point in time. Incidence rates increase over time and peak during mid to late adolescence. Similarly, results of the National Comorbidity Survey Replication showed a lifetime prevalence of 12.0% of males and 7.1% of females; median age of onset was 11.6 years (Nock, Kazdin, Hiripi, & Kessler, 2006).

Authors of the DSM-IV-TR proposed that CD is part of a developmental pathway from ODD to CD to ASPD; although flawed in some ways, this hypothesis has been supported by numerous researchers (see Burke et al., 2010). Some evidence suggests that earlier onset of CD is associated with less favorable outcomes compared with late-onset CD. In addition, CD is strongly associated with future antisocial outcomes, with individuals who possess callous-unemotional traits of CD more likely to engage in serious and persistent criminal behavior (Pardini & Fite, 2010). Of particular concern to counselors is the fact that severity of CD symptoms is associated with the development of other mental health concerns including mood and substance use disorders (Nock et al., 2006).

CD has been linked to substance abuse, poverty, exposure to violence or traumatic events, and genetic and biological factors (Comer, 2013; Jiron, 2010; Weyandt et al., 2010). Neurobiological researchers have found that individuals who have CD may struggle to associate consequences and are less sensitive to punishment and reward compared with their peers, thus leading some individuals who have CD to respond less to traditional treatments that focus on connecting thoughts, feelings, and behaviors (Matthys, Vanderschuren, Schutter, & Lochman, 2012). A review of research revealed numerous risk factors for CD, including impulsivity, low IQ, low educational attainment, poor parental supervision, history of abuse, parental conflict, antisocial behavior by parents, low socioeconomic status, association with peers engaged in delinquent behavior, negative school environment, and negative community influences (Murray & Farrington, 2010).

When assessing for CD, counselors should inquire with multiple parties about clients' behavior; this is particularly important because individuals who have CD may lie or deceive others as part of their symptomatology or to avoid consequences of their behavior. Counselors should start by asking whether the client gets into trouble at home, in school, at work, or in the community. Once general concerns are identified, counselors may talk with clients, parents, and school officials to determine the likelihood that behavioral concerns meet criteria for CD.

Differential Diagnosis

Individuals who have CD may have remarkably similar diagnosis as individuals who qualify for an ASPD diagnosis. Indeed, diagnosis of CD prior to age 15 is one criterion of ASPD. Fortunately, only about one third of individuals who meet criteria for CD will go on to develop ASPD (Burke et al., 2010). When assessing for CD in an adult, counselors should consider ASPD as a primary differential diagnosis.

As noted previously in this chapter, counselors will also need to consider ADHD and other behavioral disorders when diagnosing CD. In addition, symptoms may be accounted for by DMDD or bipolar disorder. Individuals who have CD may also meet criteria for coexisting substance use disorders.

Coding, Recording, and Specifiers

There is only one general diagnostic code for CD: 312.8_ (F91._); the final digit within the code notes whether the client experienced childhood-onset type prior to age 10 years (312.81 [F91.1]), adolescent-onset type after age 10 years (312.82 [F91.2]), or unspecified onset (312.89 [F91.9]). Depending on the number and seriousness of specific symptoms, counselors must indicate whether the disorder is mild, moderate, or severe. There are no codes associated with these specifiers. Finally, the DSM-5 includes a new with limited prosocial emotions specifier for those who have poorer prognosis as indicated by two or more of the following symptoms across time and setting: lack of remorse or guilt, callous–lack of empathy, unconcerned about performance, and shallow or deficient affect (APA, 2013a).

312.33 Pyromania (F63.1)

Nothing gave me a high like setting fires did. It started off small but eventually I needed to see something just burn and burn. I was sent to prison after the last fire, and that's where I was mandated to therapy. —Demitri

Essential Features

Pyromania, often referred to as “fire setting,” occurs in approximately 1% of the population (Grant, Schreiber, & Odlaug, 2013). Identified as an obsessive-compulsive reaction in the first DSM (APA, 1952), pyromania today is more aptly defined as an impulse disorder “leading to fire setting without an identifiable motive other than taking pleasure in viewing fire and its effects” (Cermain & Lejoyeux, 2010, p. 255). The change in categorization is a result of conflicting information regarding the origin of the term pyromania. Some believe that it originated from the Greek words fire and madness, thus indicating a driving desire to set fires (i.e., an obsessive-compulsive behavior). Others argue that the origins are from the 19th-century term monomania, focusing more on a lack of impulse control (Doley, 2003). It is interesting that pyromania was not included in the DSM-II (APA, 1968) but reappeared in the DSM-III (APA, 1980) and DSM-IV-TR (APA, 2000) as part of the Impulse Control Disorders Not Elsewhere Classified chapter (APA, 2000; Cermain & Lejoyeux, 2010; Doley, 2003). In the DSM-5, this diagnosis is no longer part of Impulse Disorders Not Elsewhere Classified but instead has been included as an impulse-control disorder, along with kleptomania, within the Disruptive, Impulse-Control, and Conduct Disorders chapter. Readers should note there have been no conclusive studies linking pyromania to the obsessive-compulsive spectrum (Cermain & Lejoyeux, 2010).

Pyromania, typified by recurrent, purposeful fire-setting behaviors, is characterized by fascination and pleasure from starting or watching fires (APA, 2013a). Although it is not uncommon for people to find pleasure in setting fires, individuals with pyromania often experience intense arousal or tension leading up to the event and high levels of gratification after the fire begins (Cermain & Lejoyeux, 2010). The behavior is deliberate and purposeful, but without ill intention, such as in CD where the aim is to cause serious physical harm to others. Individuals diagnosed with pyromania will demonstrate fascination, curiosity, and attraction to everything related to fire (APA, 2013a). However, this focus is not due to an underlying motivation such as covering up a crime, protesting an injustice, or a psychotic delusion or hallucination.

Special Considerations

Fire starting typically begins in adolescence (Grant et al., 2013), and prevalence has been estimated between 2.4% and 3.5% (Cermain & Lejoyeux, 2010). In adolescents, fire setting is more common in males than in females (Soltys, 1992). Counselors should remember, however, that it is not unusual for children and adolescents to set fires experimentally. Fire starting as an essential feature of pyromania in children is rare (APA, 2013a; Cermain & Lejoyeux, 2010). In cases in which children or adolescents are not simply experimenting or motivated by boredom, counselors do need to act. Pyromania can become chronic over the life span and is associated with high rates of comorbidity with substance use disorders, affective disorders, and anxiety disorders (Cermain & Lejoyeux, 2010; Grant et al., 2013).

Among the general adult population, the lifetime prevalence for pyromania is 1%. Often associated with a wide range of antisocial behavior, individuals diagnosed with pyromania are more likely to be U.S.-born, Caucasian adult males between the ages of 18 to 35 (Vaughn et al., 2010). People living in the Western region of the United States had significantly higher instances of fire-setting behaviors than those living in the Northeast, Midwest, and South.

Counselors need to be aware of the potentially dangerous, even life-threatening, nature of this disorder. Fire setting results in hundreds of fatalities each year, with property losses estimated in the hundreds of millions annually (Vaughn et al., 2010). When engaging these clients in treatment, counselors should apply the ACA Code of Ethics (ACA, 2014), especially related to danger to others and duty to warn. In terms of screening, a pragmatic approach is best for pyromania. Counselors should directly ask the client about fire-starting behavior and inquire how many times the client has engaged in this behavior. Counselors should also carefully consider comorbid diagnoses.

As with most disruptive, impulse-control, and conduct disorders, treatment includes psychotherapeutic or psychopharmacological options (Cermain & Lejoyeux, 2010; Grant et al., 2013). Nonpharmacological options that have been established as effective are CBT, outpatient programs, and behavioral therapy. For children and adolescents, psychoeducation has often proved useful, as has collaboration with fire prevention communities and mental health agencies. There is also evidence to support multimodal interventions, including family treatment, individual psychotherapy, psychoeducation, and behavioral interventions (Cermain & Lejoyeux, 2010).

Cultural Considerations

Often associated with underdeveloped social skills and learning issues, pyromania presents in males (82%) much more than females (17%), often emerging between ages 12 and 14 (Dell'Osso, Altamura, Allen, Marazziti & Hollander, 2006; Vaughn et al., 2010). There is little research regarding pyromania within various cultures, although in a study of fire-setting behavior among the general U.S. population, Vaughn et al. (2010) found the prevalence of fire setting was higher among males and lower among African Americans and Hispanics.

Differential Diagnosis

According to the DSM-5, true instances of pyromania are very rare (APA, 2013a). Indeed, the APA reported that just 1.13% of the population reported experience with fire setting, and very few of those individuals would actually meet the additional criteria required for pyromania. Counselors working with individuals who set fires should consider whether the behavior was purposeful or accidental. In case of purposeful fire setting, more likely differential diagnoses include CD, ASPD, bipolar disorders, and schizophrenia spectrum and other psychotic disorders (APA, 2013a; Cermain & Lejoyeux, 2010; Vaughn et al., 2010). Counselors should also note that fire setting is strongly correlated with family dysfunction, a history of abuse, and school difficulties,

Coding, Recording, and Specifiers

There is only one diagnostic code for pyromania: 312.33 (F63.1); there are no specifiers associated with this disorder.

312.32 Kleptomania (F63.2)

It started out small. When I was in school, I picked up my friends' pencils. As I got older, I wanted to take things more and more. I would take the entire rack of sunglasses out of a department store. I was really good, until I got caught.—Sharon

Essential Features

Occurring 3 times as often in women as in men, kleptomania refers to continuous theft for pleasure rather than object obtainment or financial reasons (APA, 2013a). The term kleptomania originated in the 19th century with French psychiatrists Jean Dominique Etienne Esquirol and Charles Chretien Henry Marc, and cases have been noted in the literature as early as 1878 (Talih, 2011). Whereas this disorder was listed as not elsewhere classified in the DSM-IV-TR, it is a stand-alone diagnosis in the DSM-5.

Although the act of shoplifting is not uncommon, with as many as one out of 11 individuals shoplifting at some point in their lives (Grant, Odlaug, Davis & Kim, 2009), true kleptomania is very rare. According to the DSM-5, instances of kleptomania are highly uncommon, affecting just 0.3% to 0.6% of the population and just 4% to 24% of those who are arrested for shoplifting (APA, 2013a). In one study, only 0.38% of the college population actually met the criteria for this disorder (Odlaug & Grant, 2010).

The etiology of this disorder is not known; however, some theorize that it may be related to neurotransmitter systems, such as serotonergic, dopaminergic, and opioidergic (Grant, Odlaug, & Kim, 2010), or to serotonin levels in the brain (APA, 2013a). Theorists posit a strong correlation between this disorder and substance use disorders, arguing that they could be categorized together (Cermain & Lejoyeux, 2010; Vaughn et al., 2010). Moreover, individuals with this disorder do not typically present for treatment and may be secretive about their behavior because of shame or guilt. Some consequences of kleptomania include poor life quality, social impairment, employment issues, and increased risk of suicide (Kohn, 2006). High rates of incarceration are also associated with this disorder (Grant et al., 2009), and treatment is typically sought after legal action has occurred (Talih, 2011).

Like pyromania, kleptomania is characterized by recurrent, purposeful engagement in stealing for the pure pleasure of it. A sense of tension precedes initiation of the act (APA, 2013a). Unlike other acts of stealing in which there is a concrete or practical motivation for the act, the act itself is the reward in kleptomania. These individuals do not steal as a result of hallucinations or delusions or out of anger or revenge seeking (APA, 2013a).

Special Considerations

Because of the estimated 3:1 female-to-male ratio and lack of need associated with stealing, this disorder is often associated with White, middle- to upper-class women, and almost no data exist on culture or cultural implications (Kohn, 2006). The onset of kleptomania is typically in adolescence, and it can present with varying courses, including chronic, sporadic, and episodic (APA, 2013a). Believed by many to be underreported, kleptomania is usually shameful for the individual and is not talked about or typically addressed in counseling unless there is legal intervention. One clinical study involving individuals diagnosed with kleptomania demonstrated that 68.3% of these individuals had legal involvement, whereas 20.8% experienced incarceration as a result of stealing (Grant et al., 2009).

Although stealing typically begins in adolescence, it is more common for adults to present for treatment as a result of legal consequences (Talih, 2011). In terms of gender, women typically seek treatment around age 35 and men around age 50. As with pyromania, counselors should take a pragmatic approach when screening for kleptomania and should directly ask about theft and inquire how many times the client has engaged in this behavior. There have been few studies on the effectiveness of various treatments with this population, and most theorists base their treatment approaches on etiological beliefs about the disorder. Naltrexone (Grant, 2006) and mood stabilizers have been prescribed for treatment of kleptomania with some success, although they are not indicated for the disorder. Furthermore, CBT and behavioral treatments have been used with some success (Kohn, 2006).

Differential Diagnosis

When working with individuals who are involved in shoplifting, counselors may consider more likely differential diagnoses such as ordinary theft, neurodevelopmental or neurocognitive impairments, CD, ASPD, and manic episodes. Moreover, high comorbidity with many disorders, including substance use disorders (Grant et al., 2009), depressive and bipolar disorders, personality disorders, CD, and other impulse-control disorders, have been noted in the literature (APA, 2013a; Talih, 2011).

Coding, Recording, and Specifiers

There is only one diagnostic code for kleptomania: 312.32 (F63.2); there are no specifiers associated with this disorder. Counselors should note that the original DSM-5 mistakenly published the code 312.32 (F63.3) for kleptomania. This is incorrect, and the code of F63.2 should be used.