trouble with diagnosing Disruptive, Impulse-Control, and Conduct Disorders

[spaceydaisy]

I'm always confused by these. There's so much overlap between ODD, intermittent explosive disorder, conduct disorder, DMDD and antisocial PD.

For example, the DSM criteria on ODD doesn't specify that it's a diagnosis exclusive to children/adolescents but most of the descriptors refer to children and adolescents while also referring to prevalence in adults. It also specifically says ODD and conduct disorder can be comorbid but that ODD symptoms are less severe than conduct disorder.

DSM says that conduct disorder can persist into adulthood, but I don't see how that wouldn't then be diagnosed as antisocial personality disorder, which is mutually exclusive with conduct disorder.

DMDD cannot be diagnosed past 18 yo, but does the diagnosis get changed to something else? Like dysthymia?

I did learn DMDD cannot coexist with ODD or IED and DMDD will be the prevailing diagnosis. Pretty clear cut on that.

Any tips on differentiating these and thoughts on ODD and DMDD in adults?

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[Merovinge]

DMDD was essentially created as a construct to reduce "bipolar, unspecified" (aka wide-band pediatric bipolar) diagnosis in children. There clearly exists children who have such raw affective instability that they are clinically impaired but do not have markedly episodic sx ala bipolar disorder. When these children reach adulthood initial data actually showed that most had depression, some bipolar, and rarely a non-affective disorder like an anxiety disorder. The diagnosis does not get automatically get converted to anything and as an adult psychiatrist taking a hand-off from CAP you should be doing a complete new evaluation just as with a patient that has never seen a psychiatrist before (it's done the exact same way in peds-->adult neuro, cards, etc).

Conduct disorder has very specific diagnositic criteria based on completion of 3 different antisocial/aggression/extreme defiance type of criteria in the past year. Around 1/2 of children who meet this criteria do go on to have ASPD which has it's own diagnostic criteria that imply a much more persistent and pervasive pattern of antisocial behaviors.

ODD I have never once seen diagnosed for the first time in an adult. It generally refers to a child who struggles with following authority figures, often this is related to a poor fit between the child and authority figure but can sometimes just be related to a difficult child. I have heard CAP attendings say "ODD means the problem is with the parents, while conduct disorder means the problem is the patient"; this is definitely an overly simplistic heuristic but may help adult psychiatrists who don't deal with these disorders on a daily basis keep them a bit separate in their head.

IED is a garbage pile diagnosis to get paid by insurance for psychiatric hospitalization when nothing fits. Except for pts with ASD/ID/neurologic disorders or structural brain damage in which case they can have a pattern of behaviors that looks like IED, if an outpatient doc is only treating for IED I just sigh.

 

[spaceydaisy]

Thank you. I found your explanation pretty helpful! I saw the DSM note about DMDD origins to reduce bipolar diagnosis in children, which is interesting.

The diagnosis does not get automatically get converted to anything and as an adult psychiatrist taking a hand-off from CAP you should be doing a complete new evaluation just as with a patient that has never seen a psychiatrist before (it's done the exact same way in peds-->adult neuro, cards, etc).

That's a good point. This whole thought exercise sure enough was prompted by a handoff from CAP that included ODD and I wasn't quite sure what to do with that diagnosis--carry forward, include as "pt w/hx of ODD", etc.

 

[Merovinge]

Most ODD I am not terribly worried about carrying forward into adult psychiatry, it has no pharmacologic treatment and if other issues are arising the knowledge of ODD as a child is very unlikely to influence management. Real deal conduct disorders should definitely be carried forward, at least as a historical diagnosis, as the conversion rate to ASPD is high and one should always be very careful dealing with these individuals. Some diagnosis remain horribly overutlized in routine clinical medicine (e.g. bipolar disorder) while others are clearly under-diagnosed (most personality disorders, conduct disorder) and the later can greatly impact how you go about addressing management.