Tag Archives: Conduct Disorder

Comorbidity: Substance Abuse Disorders (SUDs)

Comorbid, or comorbidity, is literally defined as “recurring together.”  (Shiel, Jr. & Stoppler, 2008, p. 94)  For our purposes, comorbidity will refer to cases where two or more psychiatric conditions coexist, and where one of the conditions is a substance abuse disorder (SUD).  “There are 11 groups of substances specifically discussed in the DSM-IV: alcohol; amphetamines and related sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; phencyclidine and related drugs (PCP); and sedatives, hypnotics, and anxiolytics.”  (Colman, 2009, p. 741)  Any one of the above substances, or combination of the above substances, can contribute to and be related this discussion of comorbidity with SUDs.

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Although this list is by no means exhaustive, “long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders (ED), and personality disorders (PD).”  (Netherton, Holmes, & Walker, 1999, p. 248)  Increased risk of mood disorders has been documented across all substance categories and across all mood related diagnoses.  (Blaney & Millon, 2009, p. 287)  Substance-Related Disorders are commonly comorbid with many mental disorders, including Conduct Disorder in adolescents; Antisocial and Borderline Personality Disorders, Schizophrenia, Bipolar Disorder.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 204)   Schneier et al. (2010) also concluded that alcohol use disorders and social anxiety disorder (SAD) is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity.

ADHD represents a risk factor for substance abuse.  ADHD patients with a high degree of nicotine consumption may be consuming large quantities as a form of self-medication.  Nicotine and alcohol, when combined, pose a markedly greater risk for the development of other addictions.  (Ohlmeier et al., 2007, p. 542)  There is “high comorbidity between heavy drinking and heavy smoking.”  (Blaney & Millon, 2009, p. 266)  These admissions seem to support the premise that alcohol and nicotine continue to serve as “gateway drugs” for people whom suffer from ADHD.

“In terms of clinical presentation, a concurrent Personality Disorder (PD) diagnosis is associated with an earlier age of onset of alcohol-related problems, increased addiction severity, more secondary drug use, more psychological distress, and greater impairment in social functioning.  As for course in addiction treatment, a concurrent PD diagnosis has been associated with premature discontinuation of treatment, earlier relapse, poorer treatment response, and worse long-term outcome.”  (Zikos, Gill, & Charney, 2010, p. 66)  Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) Personality Disorders (PDs) appear to be particularly prevalent, perhaps because the link between substance dependency and antisocial behavior can be found genetically.  (Blaney & Millon, 2009, p. 263)

“Among individuals with schizophrenia, between 40% and 50% also meet criteria for one or more substance use disorders.”  (Blaney & Millon, 2009, p. 288)  Comorbid substance use complicates adherence to sometimes complex schizophrenia treatment regimens.  Poor adherence to treatment results in worsening of schizophrenia symptoms, relapse, worsening of overall condition, increased utilization of health care facilities, re-hospitalization, reduced quality of life, social alienation, increased substance abuse, unemployment, violence, high rates of victimization, incarceration, and death.  (Hardeman, Harding, & Narasimhan, 2010, p. 405-406)  The compounding effect of substance abuse on the quality of life for individuals with schizophrenia can’t be understated.  Substance abuse is particularly common and also worsens the course of schizophrenia.  (Buckley, Miller, Lehrer, & Castle, 2009, p. 396)

Differential diagnosis and treatment can sometimes be a troublesome proposition.  Comorbidity complicates the diagnosis, treatment, and clinical course of Substance Abuse Disorders (SUDs).  (Blaney & Millon, 2009, p. 287)  “If symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 210)  Carbaugh and Sias (2010) concluded that successful outcomes can be increased through proper diagnosis and early intervention, at least in the case of comorbid Bulimia Nervosa and substance abuse.  Prevention of substance use disorders can help alleviate or decrease much impairment in psychiatric patients in particular.  (Powers, 2007, p. 357)  Furthermore, a review of treatments for patients with severe mental illness and comorbid substance use disorders concluded that mental health treatment combined with substance abuse treatment is more effective than treatment occurring alone for either disorder or occurring concurrently without articulation between treatments.  (Hoblyn, Balt, Woodard, & Brooks, 2009, p. 54)

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

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009, Mar). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35(2), 383-402. doi: 10.1093/schbul/sbn135

Carbaugh, R. J., & Sias, S. M. (2010, Apr). Comorbidity of bulimia nervosa and substance abuse: Etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32(2), 125-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2026599321&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Hardeman, S. M., Harding, R. K., & Narasimhan, M. (2010, Apr). Simplifying adherence in schizophrenia. Psychiatric Services, 61(4), 405-408. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2006767471&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Hoblyn, J. C., Balt, S. L., Woodard, S. A., & Brooks, J. O. (2009, Jan). Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatric Services, 60(1), 50-55. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1654365811&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

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

Ohlmeier, M. D., Peters, K., Kordon, A., Seifert, J., Wildt, B. T., Weise, B., … Schneider, U. (2007, Aug). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism : International Journal of the Medical Council on Alcoholism, 42(6), 539-543. doi: 10.1093/alcalc/agm069

Powers, R. A. (2007, May). Alcohol and drug abuse prevention. Psychiatric Annals, 37(5), 349-358. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282831&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schneier, F. R., Foose, T. E., Hasin, D. S., & Heimberg, R. G. (2010, Jun). Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 40(6), 977-988. doi: 10.1017/S0033291709991231

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world  medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Zikos, E., Gill, K. J., & Charney, D. A. (2010, Feb). Personality disorders among alcoholic outpatients: Prevalence and course in treatment. Canadian Journal of Psychiatry, 55(2), 65-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1986429431&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

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