Disruptive, Impulse-Control, and Conduct Disorders and Intermittent Explosive Disorder

Time Consideration for Differentiating Adjustment Disorders from PTSD

Symptoms of adjustment disorder generally begin three months after the traumatic event or life change and fade six months later. Most typically, if an adjustment problem does not improve within six months, it might progress to depression (American Psychiatric Association, 2018). Albeit the manifestations of adjustment disorder and post-traumatic stress disorder (PTSD) often overlap, the primary distinction between the two illnesses is their source. Adjustment disorder is often started by a stressful event or period that is within the normal range of human experiences, such as a divorce or financial trouble. PTSD can also be a long-term disorder, manifesting itself months or years after the initial trauma. In contrast, adjustment disorder must appear within three months after the triggering event (American Psychiatric Association, 2018).

Difference between Oppositional Defiant Disorder Conduct Disorder

Control issues are present in oppositional defiant disorder. It is characterized by a 6-month sequence of agitated state, confrontational conduct, or vindictiveness (Townsend & Morgan, 2018). Conduct disorder encompasses issues with being controlled and the desire to assert control over others. A conduct disorder has a pattern of behavior that is repeated and persistent in which basic rights or important age-appropriate societal standards or laws are broken. Oppositional defiant disorder and conduct disorder have a developmental link in that most instances of conduct disorder formerly would have met the criteria for oppositional defiant disorder, at least in situations where conduct disorder appears before puberty (Townsend & Morgan, 2018).

Intermittent Explosive Disorder

Differential Diagnoses

Attention deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, as well as autism spectrum disorder are all examples of behavioral disorders whereby Individuals suffering from these childhood illnesses may experience spontaneous violent outbursts (American Psychiatric Association, 2018). Individuals with ADHD are traditionally impulsive, which can lead to impulsive aggressive temper tantrums.  Persons with conduct disorder may have spontaneous, aggressive outbursts, and the aggressiveness typified by the diagnostic criteria is proactive and predatory (American Psychiatric Association, 2018). Temper tantrums and verbal disputes with authoritative figures are characteristic of oppositional defiant disorder aggression, but impulsive violent outbursts in intermittent explosive disorder are in reaction to a larger range of stimuli and include physical attack.

Diagnosis and Reasoning

My diagnosis is Intermittent explosive disorder (IED), a psychiatric illness characterized by impulsive angry outbursts or hostility regularly. The episodes are out of context to the triggering circumstance and create severe distress. Intermittent explosive disorder patients have limited endurance for frustration and adversity. They exhibit normal, proper conduct aside from their angry outbursts. Temper outbursts, verbal disputes, physical confrontations, and aggressiveness might all occur. One of the impulse control diseases is intermittent explosive disorder.

According to the American Psychiatric Association (2013), IED patient is diagnosed by

A. Repetitive behavior outbursts resulting from an inability to regulate violent impulses, indicated by any of the following;

1. Verbal or physical hostility directed against objects, pets, or other people, happening biweekly on average for three months. The patient’s partner claims that between episodes, he is a good and charming man who begins conflicts with her around twice a week.

2. Three behavioral tantrums involving property destruction or damage and/or violent abuse involving bodily injury to animals or other people during a 12-month period. The patient confesses to several events of this sort and has been involved in fights on a regular basis since their late youth.

B. The level of aggression displayed during the recurring outbursts is wildly out of proportion to the triggering psychological stresses. The patient threatened to “rip (your) throat out with (my) bare hands.”

C. The recurring hostile outbursts are not planned.

D. Recurrent violent outbursts create either significant anguish in the individual or impairment in vocational or interpersonal functioning or are linked to financial or legal problems. In his late twenties, he was also dismissed from many jobs owing to his “quick temper” with employees who were attempting to “slight him.”

Additional Questions to Ask

To further strengthen my diagnosis, I will inquire about the age of commencement of the ailment; the chronological age is at least six years. I’ll also ask if the recurring angry episodes may be accounted for by some other mental disease, such as depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, psychotic disorder, antisocial personality disorder, or borderline personality disorder (American Psychiatric Association, 2018). I will also do a medical assessment to ensure that the outburst was not caused by another medical issue, such as head trauma, or by the metabolic responses of a substance, drug of abuse, or medicine.

Medication Recommendations And Rationale

According to the National Institutes of Health (2021), healthcare practitioners commonly prescribe the following pharmaceutical classes for IED: antidepressants, antipsychotics, anticonvulsants, antianxiety medicines, and mood stabilizers. The best-researched medicine for treating intermittent explosive disorder is fluoxetine, a selective serotonin reuptake inhibitor (NIH, 2021). Phenytoin, lithium, oxcarbazepine, and carbamazepine are among other drugs that are recommended for IED.

Boxed caution is that fluoxetine doubles the risk of suicidal thoughts and conduct in children, teenagers, and young adults. Monitor patients of all ages who begin antidepressant therapy for worsening and the onset of suicidal thoughts and behavior. According to Amer (2018), among mental health patients, lack of insight is the most significant predictor of the inability to give informed consent. Amer (2018) demonstrates that patients with mental illness in the care unit have the ability to choose treatment decisions; however, the judgment of competence is precise to the distinct therapies verdict that is made; a client with a severe mental illness may be inept in some aspects but capable of deciding on a particular treatment in other situations.

Laboratory Diagnosis

Substance use disorders and blood electrolyte levels are two potential laboratory diagnostic tests for the intermittent explosive disorder (Townsend & Morgan, 2018).

Screening Tools

The IED screening questionnaire (IED-SQ) can determine the likelihood of developing IED. It may also aid in detecting symptoms and determining whether further assessment is required. On the other hand, the IED-SQ does not offer an official diagnosis but merely assesses the probability that one’s symptoms are caused by IED. The IED-SQ is a viable and accurate screening method for DSM-5 IED diagnosis. According to Coccaro et al. (2019), the IED-SQ demonstrates a high agreement with the DSM-5 IED diagnosis. Furthermore, the aggressiveness levels for DSM-5 IED participants are the same as they meet the DSM-5 IED criterion by best-estimate and IED-SQ, showing close identity for the two diagnostic techniques. The IED-SQ has an outstanding sensitivity, specificity, positive/negative predictive power, and overall accuracy.

Therapy Modalities

Cognitive behavioral approaches for IED had a considerable favorable effect, according to Costa et al. (2018). Costa et al. (2018) identified a significant impact factor for influence on aggression/anger scores in individuals who underwent individual CBT. CBT for IED should include follow-up sessions every week after the treatment to address relapse mitigation, reinforce taught skills, and strengthen the intrinsic psychotherapist. According to Costa et al. (2018), CBT for IED, whether in a group or individual session, helps decrease aggressive behavior. Group therapy may be very useful for IED because it allows people to engage with one another and exercise social and assertive skills, which is a big concern in IED.

References

Amer, A. B. (2018). Informed consent in adult psychiatry. Oman Medical Journal28(4), 228–231. https://doi.org/10.5001/omj.2013.67

American Psychiatric Association. (2018). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

Coccaro, E. F., Lee, R. J., & McCloskey, M. S. (2019). Clinical approach and assessment of intermittent explosive disorder. In E. F. Coccaro & M. S. McCloskey (Eds.), Intermittent Explosive Disorder (pp. 185–197). Elsevier.

Costa, A. M., Medeiros, G. C., Redden, S., Grant, J. E., Tavares, H., & Seger, L. (2018). Cognitive-behavioral group therapy for intermittent explosive disorder: description and preliminary analysis. Revista Brasileira de Psiquiatria (Sao Paulo, Brazil: 1999)40(3), 316–319. https://doi.org/10.1590/1516-4446-2017-2262

NIH. (2021). Medication treatments. Https://www.nichd.nih.gov/. https://www.nichd.nih.gov/health/topics/fragilex/conditioninfo/medicationtreatments

Townsend, M., & Morgan, K. (2018). Pocket guide to psychiatric nursing, 10e. F.A. Davis.

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