Externalizing disorder

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Externalizing disorders (or externalising disorders) are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual's environment, which cause impairment or interference in life functioning. In contrast to individuals with internalizing disorders who internalize (keep inside) their maladaptive emotions and cognitions, such feelings and thoughts are externalized (manifested outside) in behavior in individuals with externalizing disorders. Externalizing disorders are often specifically referred to as disruptive behavior disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder) or conduct problems which occur in childhood. Externalizing disorders, however, are also manifested in adulthood. For example, alcohol- and substance-related disorders and antisocial personality disorder are adult externalizing disorders. [1] Externalizing psychopathology is associated with antisocial behavior, which is different from and often confused for asociality.

Contents

Signs and symptoms

Externalizing disorders often involve emotion dysregulation problems and impulsivity that are manifested as antisocial behavior and aggression in opposition to authority, societal norms, and often violate the rights of others. [2] [3] Some examples of externalizing disorder symptoms include, often losing one's temper, excessive verbal aggression, physical aggression to people and animals, destruction of property, theft, and deliberate fire setting. [2] As with all DSM-5 mental disorders, an individual must have functional impairment in at least one domain (e.g., academic, occupational, social relationships, or family functioning) in order to meet diagnostic criteria for an externalizing disorder. [4] Moreover, an individual's symptoms should be atypical for their cultural and environmental context and physical medical conditions should be ruled out before an externalizing disorder diagnosis is considered. [5] Diagnoses must be made by qualified mental health professionals. DSM-5 classifications of externalizing disorders are listed herein, however, ICD-10 can also be used to classify externalizing disorders. More specific criteria and examples of symptoms for various externalizing disorders can be found in the DSM-5.[ citation needed ]

DSM-5 classification

There are no specific criteria for "externalizing behavior" or "externalizing disorders". Thus, there is no clear classification of what constitutes an externalizing disorder in the DSM-5. [2] [6] Attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), antisocial personality disorder (ASPD), pyromania, kleptomania, intermittent explosive disorder (IED), and substance-related disorders are frequently referred to as externalizing disorders. [1] [2] [3] [7] Disruptive mood dysregulation disorder has also been posited as an externalizing disorder, but little research has examined and validated it to date given its recent addition to the DSM-5, and thus, it is not included further herein. [8] [9]

Attention-deficit/hyperactivity disorder

Inattention ADHD symptoms include: "often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities," "often has difficulty sustaining attention in tasks or play activities," "often does not seem to listen when spoken to directly," "often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace," "often has difficulty organizing tasks and activities," "often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort," "often loses things necessary for tasks or activities," "is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts)," and "is often forgetful in daily activities." [10]

Hyperactivity and impulsivity ADHD symptoms include: "often fidgets with or taps hands or feet or squirms in seat," "often leaves seat in situations when remaining seated is expected," "often runs about or climbs in situations where it is inappropriate," "is often unable to play or engage in leisure activities quietly," "is often "on the go," acting as if "driven by a motor," "often talks excessively," "often blurts out an answer before a question has been completed," "often has difficulty waiting his or her turn," and "often interrupts or intrudes on others." [10]

In order to meet criteria for an ADHD diagnosis, an individual must have at least six symptoms of inattention and/or hyperactivity/impulsivity, have an onset of several symptoms prior to age 12 years, have symptoms present in at least two settings, have functional impairment, and have symptoms that are not better explained by another mental disorder. [10]

Oppositional defiant disorder

ODD symptoms include: "often loses temper," "is often touchy or easily annoyed," "is often angry and resentful," "often argues with authority figures, or for children and adolescents, with adults," "often actively defies or refuses to comply with requests from authority figures or with rules," "often deliberately annoys others," and "often blames others for his or her mistakes or misbehavior." [2] In order to receive an ODD diagnosis, individuals must have at least four symptoms from above for at least six months (most days for youth younger than five years) with at least one individual who is not a sibling, which causes impairment in at least one setting. [2] Rule outs for a diagnosis include symptoms occurring concurrently during an episode of another disorder. [2]

Conduct disorder

CD symptoms include "often bullies, threatens, or intimidates others," "often initiates physical fights," "has used a weapon that can cause serious physical harm to others," "has been physically cruel to people," "has been physically cruel to animals," "has stolen while confronting a victim," "has forced someone into sexual activity," "has deliberately engaged in fire setting with the intention of causing serious damage," "has deliberately destroyed others' property (other than by fire setting)," "has broken into someone else's house, building, or car," "often lies to obtain goods or favors or to avoid obligations," "has stolen items of nontrivial value without confronting a victim," "often stays out at night despite parental prohibitions, beginning before age 13 years," "has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period," and "is often truant from school, beginning before age 13 years." [2] In order to receive a CD diagnosis, individuals must have three of these symptoms for at least one year, at least two symptoms for at least six months, be impaired in at least one setting, and not have an antisocial personality disorder diagnosis if 18 years or older. [2]

Antisocial personality disorder

ASPD symptoms include: "failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest," "deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure," "impulsivity or failure to plan ahead," "irritability and aggressiveness, as indicated by repeated physical fights or assaults," "reckless disregard for safety of self or others," "consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations," and "lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another." [11] In order to meet diagnostic criteria for ASPD, an individual must have "a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years," three or more of the above symptoms, be at least age 18 years, have a conduct disorder onset before age 15 years, and not have antisocial behavior exclusively during schizophrenia or bipolar disorder. [11]

Pyromania

Pyromania symptoms include: "deliberate and purposeful fire setting on more than one occasion," "tension or affective arousal before the act," "fascination with, interest in, curiosity about, or attraction to fire and its situational contexts," and "pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath." [2] In order to receive a pyromania diagnosis, "the fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment." [2] A conduct disorder diagnosis, manic episode, or antisocial personality disorder diagnosis must not better account for the fire setting in order to receive a pyromania diagnosis. [2]

Kleptomania

Kleptomania symptoms include: "recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value," "increasing sense of tension immediately before committing the theft," and "pleasure, gratification, or relief at the time of committing the theft." [2] In order to receive a kleptomania diagnosis, "the stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination." [2] Additionally, in order to receive a diagnosis, "the stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder." [2]

Intermittent explosive disorder

IED symptoms include "recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following: 1) Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals. 2) Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period." [2] In order to receive an IED diagnosis, "the magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors," "the recurrent aggressive outbursts are not premeditated" and "are not committed to achieve some tangible objective." [2] Additionally, to receive an IED diagnosis, an individual must be six years or older (chronologically or developmentally), have functional impairment, and not have symptoms better explained by another mental disorder, medical condition, or substance. [2]

Substance use disorders

According to the DSM-5, "the essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems." [12] Given that at least 10 separate classes of drugs are covered in the DSM-5 Substance-Related and Addictive Disorders section, [12] it is outside the scope of this article, and referral to the DSM-5 [12] for more information on signs and symptoms is advised.

Comorbidity

Externalizing disorders are frequently comorbid or co-occurring with other disorders. [13] [14] Individuals who have the co-occurrence of more than one externalizing disorder have homotypic comorbidity, whereas individuals who have co-occurring externalizing and internalizing disorders have heterotypic comorbidity. [15] It is not uncommon for children with early externalizing problems to develop both internalizing and further externalizing problems across the lifespan. [15] [16] [17] Additionally, the complex interplay between externalizing and internalizing symptoms across development could explain the association between these problems and other risk behaviors, that typically initiate in adolescence (such as antisocial behaviors and substance use). [18]

Stigma

Consistent with many mental disorders, [19] individuals with externalizing disorders are subject to significant implicit and explicit forms of stigma. [20] Because externalizing behaviors are salient and difficult to conceal, individuals with externalizing disorders may be more susceptible to stigmatization relative to individuals with other disorders. [21] Parents of youth with childhood mental disorders, such as ADHD and ODD, are frequently stigmatized when parenting practices are strongly implicated in the etiology or cause of the disorder. [21] Educational and policy-related initiatives have been proposed as potential mechanisms to reduce stigmatization of mental disorders. [22]

Psychopathic traits

Individuals with psychopathic traits, including callous-unemotional (CU) traits, represent a phenomenologically and etiologically distinct group with severe externalizing problems. [23] Psychopathic traits have been measured in children as young as two-years-old, [23] are moderately stable, [23] [24] are heritable, [24] and associated with atypical affective, [23] [24] cognitive, personality, and social characteristics. [23] Individuals with psychopathic traits are at risk for poor response to treatment, [25] however, some data suggest that parent management training interventions for youth with psychopathic traits early in development may have promise. [23] [24] [25]

Developmental course

ADHD often precedes the onset of ODD, and approximately half of children with ADHD, combined type also have ODD. [10] ODD is a risk factor for CD and frequently precedes the onset of CD symptoms. [26] Children with an early onset of CD symptoms, with at least one symptom before age 10 years, [2] are at risk for more severe and persistent antisocial behavior continuing into adulthood. [26] [27] Youth with early-onset conduct problems are particularly at risk for ASPD (note that an onset of CD prior to age 15 is part of the diagnostic criteria for ASPD), [2] whereas CD is typically limited to adolescence when youth's CD symptoms begin during adolescence. [26]

Treatment

Despite recent initiatives to study psychopathology along dimensions of behavior and neurobiological indices, which would help refine a clearer picture of the development and treatment of externalizing disorders, the majority of research has examined specific mental disorders. [28] Thus, best practices for many externalizing disorders are disorder-specific. For example, substance use disorders themselves are very heterogeneous and their best-evidenced treatment typically includes cognitive behavioral therapy, motivational interviewing, and a substance disorder-specific detoxification or psychotropic medication treatment component. [29] [30] The best-evidenced treatment for childhood conduct and externalizing problems more broadly, including youth with ADHD, ODD, and CD, is parent management training, a form of cognitive behavioral therapy. [31] [32] [33] [34] [35] Additionally, individuals with ADHD, both youth and adults, are frequently treated with stimulant medications (or alternative psychotropic medications), especially if psychotherapy alone has not been effective in managing symptoms and impairment. [36] [37] [38] Psychotherapy [39] and medication [40] interventions for individuals with severe, adult forms of antisocial behavior, such as antisocial personality disorder, have been mostly ineffective. An individual's comorbid psychopathology may also influences the course of treatment for an individual. [15]

History

The classification for several externalizing disorders changed from DSM-IV to DSM-5. ADHD, ODD, and CD were previously classified in the Attention-deficit and Disruptive Behavior Disorders section in DSM-IV. [41] Pyromania, kleptomania, and IED were previously classified in the Impulse-Control Disorders Not Otherwise Specified Section of DSM-IV. ADHD is now categorized in the Neurodevelopmental Disorders section in DSM-5. [10] ODD, CD, pyromania, kleptomania, and IED are now categorized in the new Disruptive, Impulse-Control, and Conduct Disorders chapter of DSM-5. [2] Overall, there were many changes made to the DSM from the transition of DSM-IV-TR to DSM-5, which was somewhat controversial. [42]

See also

Related Research Articles

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention, while the depressive episodes last at least 2 weeks.

Externalization is a term used in psychoanalytic theory which describes the tendency to project one's internal states onto the outside world. It is generally regarded as an unconscious defense mechanism, thus the person is unaware they are doing it. Externalization takes on a different meaning in narrative therapy, where the client is encouraged to externalize a problem in order to gain a new perspective on it.

A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health.

<span class="mw-page-title-main">Attention deficit hyperactivity disorder</span> Neurodevelopmental disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by executive dysfunction occasioning symptoms of inattention, hyperactivity, impulsivity and emotional dysregulation that are excessive and pervasive, impairing in multiple contexts, and developmentally-inappropriate.

<span class="mw-page-title-main">Conduct disorder</span> Developmental disorder

Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckless breaking of rules, in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors", and is often seen as the precursor to antisocial personality disorder; however, the latter, by definition, cannot be diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and in such cases can be treated with family therapy, as well as behavioral modifications and pharmacotherapy. It may also be caused by environmental lead exposure. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.

Antisocial personality disorder (ASPD) is a personality disorder defined by a chronic pattern of behavior that disregards the rights and well-being of others. People with ASPD often exhibit behavior that conflicts with social norms, leading to issues with interpersonal relationships, employment, and legal matters. The condition generally manifests in childhood or early adolescence, with a high rate of associated conduct problems and a tendency for symptoms to peak in late adolescence and early adulthood.

<span class="mw-page-title-main">Obsessive–compulsive personality disorder</span> Personality disorder involving orderliness

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

Adult Attention Deficit Hyperactivity Disorder is the persistence of attention deficit hyperactivity disorder (ADHD) into adulthood. It is a neurodevelopmental disorder, meaning impairing symptoms must have been present in childhood, except for when ADHD occurs after traumatic brain injury. Specifically, multiple symptoms must be present before the age of 12, according to DSM-5 diagnostic criteria. The cutoff age of 12 is a change from the previous requirement of symptom onset, which was before the age of 7 in the DSM-IV. This was done to add flexibility in the diagnosis of adults. ADHD was previously thought to be a childhood disorder that improved with age, but recent research has disproved this. Approximately two-thirds of childhood cases of ADHD continue into adulthood, with varying degrees of symptom severity that change over time and continue to affect individuals with symptoms ranging from minor inconveniences to impairments in daily functioning.

Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organization (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is used in assessing mental health and developmental disorders in children up to age five.

Cognitive disengagement syndrome (CDS) is a syndrome characterized by developmentally inappropriate, impairing, and persistent levels of decoupled attentional processing from the ongoing external context and resultant hypoactivity. Symptoms often manifest in difficulties with staring, mind blanking, absent-mindedness, mental confusion and maladaptive mind-wandering alongside delayed, sedentary or slow motor movements. To scientists in the field, it has reached the threshold of evidence and recognition as a distinct syndrome.

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness." This behavior is usually targeted toward peers, parents, teachers, and other authority figures, including law enforcement officials. Unlike conduct disorder (CD), those with ODD do not generally show patterns of aggression towards random people, violence against animals, destruction of property, theft, or deceit. One-half of children with ODD also fulfill the diagnostic criteria for ADHD.

<span class="mw-page-title-main">Sadistic personality disorder</span> Former personality disorder involving sadism

Sadistic personality disorder is an obsolete term for a proposed personality disorder defined by a pervasive pattern of sadistic and cruel behavior. People who fitted this diagnosis were thought to have a desire to control others and to have accomplished this through use of physical or emotional violence. The diagnosis proposal appeared in the appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), however it was never put to use in clinical settings and later versions of the DSM had it removed. Among other reasons, psychiatrists believed it would be used to legally excuse sadistic behavior.

Emotional and behavioral disorders refer to a disability classification used in educational settings that allows educational institutions to provide special education and related services to students who have displayed poor social and/or academic progress.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

Personality disorders (PD) are a class of mental health conditions characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

In personality pathology, dimensional models of personality disorders conceptualize personality disorders as qualitatively rather than quantitatively different from normal personality. They consist of extreme, maladaptive levels of certain personality characteristics. Within the context of personality psychology, a "dimension" refers to a continuum on which an individual can have various levels of a characteristic, in contrast to the dichotomous categorical approach in which an individual does or does not possess a characteristic. According to dimensional models personality disorders are classified according to which characteristics are expressed at which levels. This stands in contrast to the traditional categorical models of classification, which are based on the boolean presence or absence of symptoms and do not take into account levels of expression of a characteristic or the presence of any underlying dimension.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

Robert Frank Krueger is Hathaway Distinguished Professor of Clinical Psychology and Distinguished McKnight University Professor in the Department of Psychology at the University of Minnesota. He is known for his research on personality psychology, clinical psychology, quantitative psychology, developmental psychology, personality disorders, behavioral genetics, and psychopathology. He is the co-editor-in-chief of the Journal of Personality Disorders.

<span class="mw-page-title-main">Hierarchical Taxonomy of Psychopathology</span> Classification of mental health problems

The Hierarchical Taxonomy Of Psychopathology (HiTOP) consortium was formed in 2015 as a grassroots effort to articulate a classification of mental health problems based on recent scientific findings on how the components of mental disorders fit together. The consortium is developing the HiTOP model, a classification system, or taxonomy, of mental disorders, or psychopathology, aiming to prioritize scientific results over convention and clinical opinion. The motives for proposing this classification were to aid clinical practice and mental health research. The consortium was organized by Drs. Roman Kotov, Robert Krueger, and David Watson. At inception it included 40 psychologists and psychiatrists, who had a record of scientific contributions to classification of psychopathology The HiTOP model aims to address limitations of traditional classification systems for mental illness, such as the DSM-5 and ICD-10, by organizing psychopathology according to evidence from research on observable patterns of mental health problems.

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