Tag Archives: CD

Comparing and Contrasting Dissociative Identity Disorder (DID, Multiple Personality Disorder) with Conversion Disorder (CD)


Dissociative Identity Disorder and Conversion Disorder are similar in that they both stem from stressful events.  In Dissociative Identity Disorder a personality is formed when extreme child abuse or sexual abuse is experienced.  With Conversion Disorder it is a more recent event like a rape or physical or emotional abuse. Other than this similarity the two disorders are quite different.

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Dissociative Identity Disorder is a disorder in which the person affected suffers from as little as 2 distinct personalities and can suffer from as many as 100 or more.  Each personality has a very distinct identity, and will often take control of the person and how they act.  Because of the different identities taking over the people lose time.  They don’t remember the period of time that they were not in control and then have a hard time understanding why everything is different, especially in extreme cases when the other identity takes over for years at a time.  Usually an alternate identity takes over when the primary identity experiences something overly stressful.  It is common for people with this disorder to have other disorders or to have problems with substance abuse.  While DID has been known to last a lifetime, treatment can help.  Treatment usually involves psychotherapy and helps the person to integrate the identities into one.  It can be a painful process as well as time consuming, but according to people who have been able to achieve integration, it is definitely worth it.

Alternatively Conversion Disorder affects people in their sensory areas or physically where voluntary movement is concerned.  It is known to be a somatoform disorder and is said to be a large part of why people visit their primary care physicians.  Basically when people shove their emotions and stress too far inward they turn into physical symptoms.  This is called converting.  The conversion of these symptoms can cause a patient to contact their caregiver nine times as often.  The patient does not control the symptoms and can have a surprisingly painful beginning, and diagnosis can become complicated by a true physical illness.

Conversion Disorder has specific risk factors which include the fact that someone is female, men are less likely to receive this diagnosis.  This diagnosis is more common in the teen years, if there is someone in the family who is already receiving treatment for Conversion Disorder, it is likely to continue in the family line.

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Oppositional Defiant Disorder (ODD) | Conduct Disorder (CD) | Disruptive Behavior Disorders


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While Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are both categorized under the general heading of “Disruptive Behavior Disorders,” there are specific features that allow us to compare and contrast them during diagnosis.  Primary features of ODD include a pattern of negativistic, defiant, noncompliant, and uncooperative behaviors.  Primary features of CD include a pattern of behavior in which the basic rights of others and/or major age-appropriate norms or rules are violated.  The primary feature that distinguishes ODD from CD is the emphasis in CD on the recurrent violation of the rights of others and/or societal norms and rules.   (Netherton, Holmes, & Walker, 1999, p. 118)  The diagnosis (of ODD) is not made if the disturbance in behavior occurs exclusively during the course of a Psychotic or Mood Disorder; or if the criteria are met for Conduct Disorder of Antisocial Personality Disorder (in an individual over age 18 years).  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 100)

Despite our ability to differentiate the diagnoses, current etiological evidence suggests that they do follow a common developmental course.  Genetic, temperamental, family interaction and environmental stress variables have all been implicated in the development of ODD/CD.  (Netherton et al., 1999, p. 122)  In a comprehensive study of gender and its relationship to genetic influence of ODD/ADHD, Derks and associates (2007) concluded that the size of the genetic influences does not depend on the child’s sex, but partly different genes are expressed in boys and girls.  They also found that parent and teacher ratings may be inconsistent because qualitative description depending on the context in which they are observed.  Compensating for that inconsistency, there is no quantitative evidence indicating that ODD/CD is more common in boys than girls.  (Derks, Dolan, Hudziak, Neale, & Boomsma, 2007)

These children often exhibit deficits in social skills, including difficulties developing and maintaining peer relationships.  They are more aggressive, less empathetic, and more deficient in the social-problem-solving skills, and they tend to misperceive the social environment, often incorrectly attributing hostile intentions to others.  (Netherton et al., 1999, p. 119)  Considering these deficiencies are displayed in childhood, I would posit the question; how do they fare as adults?  A recent study utilized data from a 20-year community follow-up study to investigate the extent to which youth irritability (one of the DSM-IV criteria for ODD) is a risk for adult psychiatric disorders.  The results measured irritability in children and found that they could reliably predict depressive disorders and generalized anxiety disorder in same subject adults.  (Stringaris, Cohen, Pine, & Leibenluft, 2009)

A recent study performed by Glantz and associates (2009) focused on early onset mental disorders and their ability predict substance dependence into adulthood.  The study chose to focus on dependence rather than abuse because mental disorders are known to predict the dependence more strongly than abuse.  Glantz and associates inquired about the efficacy mounting mental health treatments in childhood to produce results in substance dependence among adults.  Although the study concluded that “treatment of prior mental disorders would not be a cost-effective way to prevent substance dependence,” they did acknowledge that “prevention of substance dependence might be considered an important secondary outcome of interventions for early-onset mental disorders.”  (Glantz, Anthony, Berglund, & Degenhardt, 2009)  This study serves to emphasize the lifelong benefits we can provide children as our efforts continue to yield dividends into their adult lives.

Ramchand and associates raised the stakes and underscored the possible outcomes of we fail to address ODD/CD in childhood.  They examined outcomes for adolescent offenders, and gave them the opportunity to express how they were faring in young adulthood.  Seven years after court referral to long-term residential group-home care, 12 of our sample of 449 youths were dead before turning 25, almost one third were in prison or jail, close to one half did not have a high-school diploma, two thirds reported ongoing criminal activity, and almost two thirds reported illegal drug use in the previous year (and more than half of those acknowledged the use of hard drugs).  Nine of the 11 known causes of death involved gunshot wounds or murder, highlighting the dangerous conditions to which many delinquents are exposed even after long-term rehabilitative care.  Supplemental analyses provided further evidence of this danger: 60% of the 383 surveyed respondents reported having been shot at with a gun, and 19% reported having suffered a gunshot wound.  (Ramchand, Morral, & Becker, 2009)

Despite our challenges in determining a specific etiology, and subsequently diagnosing ODD/CD, it is clear that there is an unprecedented demand for work within the context of these two pathologies.  Aside from the fact that they are among the most commonly referred for professional help, the stakes couldn’t be higher to resolve these mental health issues in childhood so as to prevent future problems for our clients in the future.  Although current research provides a baseline for analysis, further research is needed to determine the specific effects mental health treatment in children as it relates to the punitive effects it can have leading into adulthood.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Derks, E., Dolan, C., Hudziak, J., Neale, M., & Boomsma, D. (2007, Jul). Assessment and etiology of attention deficit hyperactivity disorder and oppositional defiant disorder in boys and girls. Behavior Genetics, 37(4), 559-566. doi: 10.1007/s10519-007-9153-4

Glantz, M. D., Anthony, J. C., Berglund, P. A., & Degenhardt, L. (2009, Aug). Mental disorders as risk factors for later substance dependence: estimates of optimal prevention and treatment benefits. Psychological Medicine, 39(8), 1365-1378. doi: 10.1017/S0033291708004510

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Ramchand, R., Morral, A. R., & Becker, K. (2009, May). Seven-year life outcomes of adolescent offenders in los angeles. American Journal of Public Health, 99(5), 863-871. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1683162651&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Stringaris, A., Cohen, P., Pine,  . S., & Leibenluft, E. (2009, Sep). Adult outcomes of youth irritability: A 20-year prospective community-based study. The American Journal of Psychiatry, 166(9), 1048-1055. doi: 10.1176/appi.ajp.2009.08121849

Disruptive Behavior: ODD/CD ADHD


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Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), along with the comorbid Attention-Deficit/Hyperactivity Disorders (ADHD), are among the most prevalent and the most treated pathologies globally. Children who exhibit overactive, noncompliant, oppositional, and aggressive behaviors are among the most commonly referred for professional help. (Netherton, Holmes, & Walker, 1999, p. 118) As clinicians, the question isn’t if we will run into it, it’s more of a question of when… and so I consider ODD and CD, along with ADHD, to be among the most important and clinically significant studies we will likely undertake.

Complaints about ODD/CD children include annoying or aversive interpersonal behaviors (e.g., recurrent yelling, temper tantrums, impulsivity, excessive motor activity, lying, stealing), noncompliance with authority figures, defiance of social norms, and physically aggressive behaviors (e.g., hitting, fighting). (Netherton et al., 1999, p. 118) They are more aggressive, less empathetic, and more deficient in social-problem-skills, and they tend to misperceive the social environment. (Netherton et al., 1999, p. 119) In my experience, all of the above apply, and more. I have witnessed or seen presentations that coexist with ADHD, major depression, low self-esteem, and alcohol/substance abuse. Although my experience in a clinical setting is limited, I have rarely met individuals who exhibit ODD/CD traits that do not also exhibit symptoms of other pathologies. I believe the interplay of these comorbid pathologies has a compounding effect, intensifying the behaviors, thereby making them more difficult to diagnose and even more difficult to treat.

I was particularly drawn to the developmental course of the pathology, and I was wholly unaware that behaviors could begin to develop as early as infancy. Pre-reading, I was prone to implicate family interaction and environmental stress variables before genetic or temperamental. However, I think I will defer that judgment, as it would appear that heredity and temperamental inconsistencies (I almost used defects here, but it seemed too condemning?) play a significant role in the etiology. I was not at all surprised that the typical developmental course gets progressively more severe with age, especially as the kids being to identify with an oppositional and delinquent peer group. (Netherton et al., 1999, p. 121)

Am I the only one to notice that males always seem to have a higher prevalence of pathology? Aside from Rett’s Disorder, which is exclusively dedicated to females, males are almost always more likely to exhibit pathological behavior. I think it’s a conspiracy.

I understood, appreciated, and agreed with the statement that “the assessment process should strive to accurately understand the child’s behavioral and emotional functioning across time and multiple settings, as well as the contexts in which the child normally functions.” (Netherton et al., 1999, p. 124) I especially appreciate the last part of the statement, and I think it is important to recognize and appreciate situations where the child does accelerate. I think that’s a key part of the assessment that was under addressed in the text, as it gives us the opportunity to demonstrate the child (during the course of the interview) that they do, indeed, “have it in them.”

Custodial parents may harbor some psychopathology (e.g., anti-social behavior, alcohol abuse, depression) that might help to maintain the child’s problems and impede treatment efforts if not also addressed. (Netherton et al., 1999, p. 125) It would suffice to say that is pretty consistent with my experience. Matter of fact, “might” implies it happens less frequently than we are probably aware. Parent Management Training (PMT) looks like an ingenious intervention if the parents are willing, I wasn’t aware there was such a thing. I wouldn’t rule out individual or group therapy as a possible outlet as well, depending on the situation.

“Treatment professionals recognize the chronic nature of the difficulties which these children experience and follow the child and the family over the long run, similar to medical follow-up of an individual with a chronic illness.” (Netherton et al., 1999, p. 133) Simply because we are able to mitigate and subsequently resolve the immediate and pressing issues surrounding the precipitating event, doesn’t necessarily mean that we have really solved the problem. Inevitably there will be underlying systemic issues in the family structure, or adjunct issues that we can continue to address that will help prevent recurrence of disruptive behaviors. I really like this proactive approach, and I think it’s imperative that we continue to impress on families that we should attempt to “get ahead” and proactively address potential issues.

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Reference
Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.