Understanding the Use of Psychotherapy and Psychotropic Medications for Oppositional Defiance and Conduct s Prof. Daniel Kaplin College of Staten Island One of the new chapters in the Diagnostic and Statistical Manual for Mental s- 5th edition (DSM-5) is the disruptive, impulse-control, and conduct disorders, which is a blending of the previously listed s Usually First Diagnosed in Infancy, Childhood, or Adolescence and Impulse-Control s Not Otherwise Specified of the DSM-IV-TR (American Psychiatric Association, 2000; American Psychiatric Association, 2000). The new DSM-5 categorizes these disorders as problems in the self-control of emotions and behaviors (American Psychiatric Association, 2013). The disorders listed in this category are oppositional defiant disorder (ODD), conduct disorder (CD), intermittent explosive disorder (IED), antisocial personality disorder (ASPD), and several other impulse-control disorders (American Psychiatric Association, 2013). This article will discuss the new diagnostic criteria and several related treatment interventions associated with ODD and CD. The reason these disorders are being isolated from the others in this category is they can be understood on a developmental continuum. More specifically, on average, ODD is detected earlier and is less severe than conduct disorder. However, it increases the risk of being diagnosed with CD. Research suggests that nearly 60% of individuals who were diagnosed with ODD develop CD (Burke et al. 2010; Turgay, 2009). If
left untreated, these individuals are at markedly higher risk for developing ASPD. See Figure 1 for the developmental pathway of these disorders. Figure 1. Oppositional Defiant Conduct Antisocial Personality Oppositional Defiant Diagnostic Criteria. The DSM-5 classifies ODD as a pattern of (a) angry/irritable mood (b) argumentative/defiant behavior or (c) vindictiveness towards a person in authority. These symptoms must last a minimum of 6 months and exhibited during interaction with at least one individual who is not a sibling. The disorder must lead to distress (to them or others) and dysfunction in one or more settings. Moreover, it cannot be better explained by psychosis, substance abuse, or another mood disorder (American Psychiatric Association, 2013). Severity ratings of the disorder have been added to the DSM-5 and are determined by the number of settings where the individual demonstrates disruption. Psychological Treatments. Unlike many psychological conditions, oppositional defiant disorder does not have a FDA drug approved for its treatment (Turgay, 2009). As a result, it is important to note that psychotherapy should be the first attempt at intervention. Individual counseling (to help learn to manage emotions), family counseling (to improve communication and relationships), parent-child interaction therapy (to give guidance to parents while they interact with their children), social skills training (to help improve peer relations), and parent training (to help the parent cope) have proven successful at treating ODD (Mayo Clinic, 2012). Pharmacological Treatments. There are no formal pharmacotherapies approved for the treatment of ODD exclusively. However, researchers have found this disorder is frequently associated with Attention-Deficit Hyperactivity (Coccaro, 2012). As a result,
psychostimulants and atomoxetine have been effective (Turgay, 2009). Similarly, there is research to suggest that mood stabilizers can be helpful to regulate impulsivity (Turgay, 2009). Turgay, Binder, Snyder, and Fisman (2002) found risperidone to be an effective drug for disruptive behaviors in general. Lastly, alpha(2)-agonists combined with stimulants can be used for ODD which co-occurs with ADHD (Turgay, 2009). Conduct Diagnostic Criteria. The DSM-5 classifies CD as a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by aggression to people or animals, destruction of property, theft, deceitfulness, and serious law violations. These symptoms are almost identical to the DSM-IV- TR criteria. These symptoms must persist for a minimum of 12 months with at least one criterion present in the past 6 months. There are three subtypes of CD: (a) childhood (b) adolescence or (c) adulthood (provided the symptoms were present earlier). These factors must lead to impairment of functioning and the person cannot meet the criteria for antisocial personality disorder (if 18 years or older). Specification should be made for whether the person presents with (a) lack of remorse (b) empathy (c) concern for their performance, or (d) expression of emotions (American Psychiatric Association, 2013). Psychological Treatments. The most effective interventions for CD involve the use of families and extended networks. For example, parent-management therapy [PMT] (used to train parents on how to modify behavior in the home), multi-systemic therapy [MST] (used to work with the individual, family, peer, school, and their environment), Problem-Solving Skills Training [PSST] (used to help parents/child learn the skills involved in effective problemsolving), Functional Family Therapy [FFT] (used to highlight the importance of importance of respecting all family members on their own terms), and Brief Strategic Family Therapy [BSFT] (used to youth's behavior by improving family relationships), and behavioral therapy (used to help control anger) are the most effective treatments for conduct disorder (Kazdin, 2002). Pharmacological Treatments. Levy and Bloch (2012) note that the most effective pharmacotherapy for conduct disorder is atypical antipsychotics. These authors suggest that Valproate or lithium as second or third options. Lastly, in cases where CD is co-occurring with
ADHD, psychostimulants should be considered. However, once again, the psychotherapy appears to be the most effective intervention for these disorders. Summary As noted above, the focus of this paper was to examine the DSM-5 changes to oppositional defiant disorder and conduct disorder. It is well documented that psychotherapy appears to be the most appropriate treatment for these disorders. However, when these disrders are coupled with ADHD or another condition, pharmacological treatments become more effective. See Figure 2 below for a summary of these disorders and their associated treatments. Figure 2 ODD CD DSM-5 Changes Substantial Very Minimal Psychotherapy Individual counseling Parent-management Parent-child therapy interaction therapy Multi-systemic therapy Social skills training Problem-Solving Skills Parent training Training Functional Family Therapy Brief Strategic Family Therapy Behavioral therapy Pharmacotherapy Psychostimulants and Atypical Atomoxetine antipsychotics Risperidone Valproate or lithium Alpha(2)-agonists Psychostimulants
References American Psychiatric Association (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, D. C.: Author. American Psychiatric Association (2013). Diagnostic and Statistical Manual for Mental Illness- Fifth Edition (DSM-V). Arlington, VA: Author. Burke, J.D., Waldman, I., & Lahey, B. B. (2010). Predictive validity of childhood oppositional defiant disorder and conduct disorder: Implications for the DSM-V. Journal of Abnormal Psychology, 119, 739 751. Kazdin, A. E. (2002). In P. E. Nathan & J. M. Gorman (Eds.). A guide to treatments that work (2nd ed.). New York: Oxford University Press Levy, T., & Bloch, Y. (2012). Pharmacotherapy for conduct disorder in children and adolescents. HaRefuah, 151, 421-426. Mayo Clinic (2012). Oppositional defiant disorder: Treatments and drugs. Retrieved October 31, 2013 from http://www.mayoclinic.com/health/oppositional-defiantdisorder/ds00630/dsection=treatments-and-drugs. Turgay, A. (2009). Psychopharmacological treatments of oppositional defiant disorder. CNS Drugs, 23, 1017. Turgay, A., Binder, C., Snyder, R., and Fisman, S. (2002). Long-term safety and efficacy of risperidone for the treatment of disruptive behavior disorders in children with subaverage IQs. Pediatrics, 110, e34.