181 - 6C91 Conduct dissocial disorder

6C91 Conduct-dissocial disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Conduct-dissocial disorder Essential (required) features • A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate social or cultural norms, rules or laws are violated is required for diagnosis. Typically, multiple behaviours are involved, including one or more of the following: • aggression towards people or animals, such as bullying, threatening or intimidating others, instigating physical fights, using weapons that can cause serious physical harm to others (such as a brick, broken bottle, knife or gun), physical cruelty to people, physical cruelty to animals, aggressive forms of stealing (e.g. mugging, purse snatching, extortion), or forcing someone into sexual activity; • destruction of property, such as deliberate fire setting with the intention of causing serious damage or deliberate destruction of others’ property (e.g. purposely breaking other children’s toys, breaking windows, scratching cars, slashing tires); • deceitfulness or theft, such as stealing items of value (e.g. shoplifting, forgery), lying to obtain goods or favours or to avoid obligations (e.g. “conning” others), or breaking into someone’s house, building or car; • serious violations of rules, such as children or adolescents repeatedly staying out all night despite parental prohibitions, repeatedly running away from home, or often skipping school or work without permission. • The pattern of behaviour must be persistent and recurrent, including multiple incidents of the types of behaviours described above over an extended period of time (e.g. at least 1 year). The mere commission of one or more delinquent acts is not sufficient for the diagnosis. • The behaviour pattern results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Specifiers for age of onset Two subtypes related to age of onset can be specified in individuals who meet the diagnostic requirements for conduct-dissocial disorder. Conduct-dissocial disorder, childhood onset • All diagnostic requirements for conduct-dissocial disorder are met. • One or more features of the disorder have clearly been present and persistent during childhood prior to adolescence (e.g. before 10 years of age). 6C91 6C91.0 Disruptive behaviour and dissocial disorders | Conduct-dissocial disorder

545 Disruptive behaviour and dissocial disorders Conduct-dissocial disorder, adolescent onset • All diagnostic requirements for conduct-dissocial disorder are met. • None of the features of the disorder were present prior to adolescence (e.g. before 10 years of age). Conduct-dissocial disorder, unspecified Additional clinical features • Individuals with conduct-dissocial disorder may be part of a delinquent peer group where delinquent activities are often conducted in association with peers. This may be particularly common among those with adolescent onset. • The relationship between conduct-dissocial disorder and oppositional defiant disorder has historically been conceptualized as hierarchical and developmental in nature, with conductdissocial disorder generally considered more severe than, and commonly preceded by, oppositional defiant disorder. However, conduct-dissocial disorder frequently co-occurs and can be diagnosed with oppositional defiant disorder, particularly among individuals with a more persistent history of behaviour problems. • Individuals with conduct-dissocial disorder with limited prosocial emotions (see p. 548) and individuals with conduct-dissocial disorder, childhood onset, are at greater risk of exhibiting a more persistent and severe pattern of antisocial behaviour over time. However, the subtypes for age of onset and the specifier for prosocial emotions are distinct characteristics that should be considered separately. In particular, childhood onset does not necessarily indicate that the individual will exhibit limited prosocial emotions. • Conduct-dissocial disorder frequently co-occurs with attention deficit hyperactivity disorder, developmental learning disorder, anxiety and fear-related disorders, mood disorders, and disorders due to substance use. Boundary with normality (threshold) • Engaging in political protests should not be regarded as indicating the presence of conductdissocial disorder. • The behaviours that contribute to a diagnosis of conduct-dissocial disorder can include criminal offences, and may entail legal or disciplinary repercussions – particularly for adolescents and adults. At the same time, many individuals who commit such criminal offences do not exhibit a persistent and recurrent pattern of antisocial behaviour in which the basic rights of others or major age-appropriate social or cultural norms, rules or laws are violated. Criminal behaviours may occur impulsively or opportunistically, or in relation Disruptive behaviour and dissocial disorders | Conduct-dissocial disorder 6C91.1 6C91.Z

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders to substance use or intoxication. Clinical assessment and diagnosis should focus on the broader pattern of behaviour rather than solely on the criminality of specific behaviours or incidents. Course features • Earlier age of onset and greater symptom severity are predictive of worse prognosis, with these individuals more likely to engage in criminal behaviour and substance abuse, and to experience additional co-occurring mental and behavioural disorder diagnoses during adulthood. • The course of conduct-dissocial disorder is highly variable, with some individuals experiencing a full remission of symptoms by adulthood. Initial symptoms of conductdissocial disorder are typically less severe in form (e.g. lying), but may progress in their severity over time (e.g. assault). There are significant individual differences in course features and progression of symptoms over time. • When conduct-dissocial disorder is present in adulthood, it has generally been preceded by a history of serious behaviour problems during childhood and adolescence. • The persistence of conduct-dissocial disorder into adulthood is often marked by continuity in types of behaviour problems (e.g. property violations in contrast to theft). Individuals with conduct-dissocial disorder who are violent during adolescence typically continue to engage in more frequent violence than their peers in adulthood. Status offences (e.g. running away, truancy) are less relevant in adulthood, but are a risk factor for continuing rule-breaking behaviour and criminal arrest. Developmental presentations • Although onset of conduct-dissocial disorder can occur in early childhood during the preschool years, typical age of onset is during early to middle adolescence. Onset of conduct-dissocial disorder is rare after the age of 16 years. Culture-related features • Assessment of conduct problems should account for contextual factors to determine whether a diagnosis is appropriate. In some cultural settings, for example, school-aged children may be away from school for long periods of seasonal employment rather than for conduct reasons. Alternatively, in communities with high levels of organized violence (e.g. gangs) or in the midst of civil conflict or war (e.g. where children as recruited as soldiers), children may be coerced into participating in interpersonal violence or property theft, which they may carry out for their own survival. A diagnosis of conduct-dissocial disorder should not be assigned in such cases. Disruptive behaviour and dissocial disorders | Conduct-dissocial disorder

547 Disruptive behaviour and dissocial disorders • Conduct-dissocial disorder in adolescents often co-occurs with disorders due to substance use – especially those associated with use of alcohol. The rates of co-occurrence are influenced by sociocultural variation in availability of substances. Sex- and/or gender-related features • Conduct-dissocial disorder is more common among males. • Males with conduct-dissocial disorder are more likely to exhibit symptoms of stealing, vandalism, fighting and school discipline problems, whereas females are more likely to exhibit lying, truancy, substance abuse, absconding and prostitution. • Males with conduct-dissocial disorder more commonly exhibit both physical and relational aggression, whereas females are more likely to exclusively exhibit relational aggression. Boundaries with other disorders and conditions (differential diagnosis) Boundary with oppositional defiant disorder For a diagnosis of conduct-dissocial disorder to be assigned, the pattern of behaviour must be severe and dissocial (i.e. violating major rules, norms, or the rights of others), such that it extends beyond the noncompliant and defiant behaviours that are characteristic of oppositional defiant disorder. However, oppositional defiant disorder and conduct-dissocial disorder frequently cooccur, particularly among adolescents and individuals with a more persistent history of behaviour problems, and may be diagnosed together if the full diagnostic requirements for each are met. Boundary with attention deficit hyperactivity disorder Individuals with attention deficit hyperactivity disorder may exhibit disruptive behaviours as a result of their impulsivity or hyperactivity; however, these disruptive behaviours are not typically severe and dissocial in nature (i.e. they do not violate major rules, norms or the rights of others), and therefore would not warrant an additional diagnosis of conduct-dissocial disorder. However, conduct-dissocial disorder and attention deficit hyperactivity disorder can co-occur, and both may be diagnosed if the full diagnostic requirements for each are met. Boundary with mood disorders Conduct problems, aggressive behaviours, risky behaviours and irritability/anger can occur in the context of mood episodes (depressive, manic, mixed or hypomanic). Moreover, in children and adolescents, depressive, manic or hypomanic mood can manifest as irritability. When the behaviour problems occur entirely in the context of mood episodes, a separate diagnosis of conduct-dissocial disorder is generally not warranted. Boundary with intermittent explosive disorder Individuals with intermittent explosive disorder may come into conflict with other people and the law because of their explosive outbursts, but these episodes do not constitute a more general pattern of antisocial behaviour characteristic of conduct-dissocial disorder (e.g. rule violations, Disruptive behaviour and dissocial disorders | Conduct-dissocial disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders lying, theft). In addition, intermittent explosive disorder is characterized by impulsive aggression, while aggression in conduct-dissocial disorder is often premeditated and instrumental. Boundary with personality disorder Conduct-dissocial disorder is not a personality disorder, although it is related to specific personality disorder categories in the clinical and research nomenclature (i.e. dissocial personality disorder, antisocial personality disorder). Personality disorder is characterized by a relatively enduring and pervasive disturbance in how individuals experience and interpret themselves, others and the world that results in maladaptive patterns of cognition, emotional experience, emotional expression and behaviour. These maladaptive patterns lead to significant problems in psychosocial functioning that are particularly evident in interpersonal relationships, manifested across a range of personal and social situations (i.e. not limited to specific relationships or situations). Individuals with personality disorder may have prominent dissocial features as an aspect of personality traits. The diagnosis of conduct-dissocial disorder is made based on a recurrent pattern of antisocial behaviour that may range in duration from a discrete period lasting a number of months to a pattern that persists across the lifespan. Conduct-dissocial disorder and personality disorder can co-occur, and both may be diagnosed if the full diagnostic requirements for each are met. Boundary with disorders due to substance use If the pattern of dissocial behaviour is limited to obtaining or using illicit substances, or if the behaviour is exclusively related to the effects of intoxication, dependence or withdrawal, conduct-dissocial disorder should not be diagnosed, and a disorder due to substance use should be considered instead. At the same time, co-occurrence of episodes of dissocial behaviour and substance use is common among individuals with conduct-dissocial disorder. This distinction may therefore depend on a complex clinical judgement that takes into account the onset, sequencing and context of the relevant behaviours. However, conduct-dissocial disorder and disorders due to substance use frequently co-occur, and both may be diagnosed if the full diagnostic requirements for each are met. Specifier applicable to oppositional defiant disorder and conductdissocial disorder Specifiers for limited or typical prosocial emotions • The with limited prosocial emotions specifier may be applied to individuals who meet the diagnostic requirements for oppositional defiant disorder or conduct-dissocial disorder and also exhibit a pattern of limited prosocial emotions sometimes referred to as “callous and unemotional traits”. Individuals with these characteristics represent a minority of those with disruptive behaviour and dissocial disorders diagnoses. The with limited prosocial emotions specifier represents a relatively more severe and less common presentation of disruptive behaviour and dissocial disorders. Disruptive behaviour and dissocial disorders | Conduct-dissocial disorder

549 Disruptive behaviour and dissocial disorders In evaluating prosocial emotions, it is important to obtain information from others who have known the individual for an extended period of time, in addition to the individual’s self-report of their own behaviours and experience. Limited or typical prosocial emotions in individuals with oppositional defiant disorder or conduct-dissocial disorder can be specified as follows. with limited prosocial emotions • In the context of a diagnosis of disruptive behaviour and dissocial disorders, this specifier represents the presence of a characteristic social-emotional pattern in which several of the following features are repeatedly manifested: • limited or absent empathy or sensitivity to others’ feelings or concern for their distress – the individual is more concerned with how events and their own behaviours affect themselves than with how they affect others, even if they cause harm; • limited or absent remorse, shame or guilt over their own behaviour (unless prompted by being apprehended), lack of concern about the consequences of their actions on others and relative indifference towards the probability of punishment; • limited or absent concern over poor/problematic performance in school, work or other important activities – the individual putting forth little effort and blaming others for their poor performance; • limited or shallow expression of emotions, particularly positive or loving feelings towards others – the individual’s emotional expression possibly appearing shallow, superficial, insincere or instrumental. • This pattern is pervasive across situations and relationships (i.e. the specifier should not be applied based on a single characteristic, a single relationship or a single instance of behaviour). • The pattern is persistent over time (e.g. at least 1 year). • Among individuals with oppositional defiant disorder, those with limited prosocial emotions tend to display a particularly extreme and stable pattern of oppositional behaviours. • Among individuals with conduct-dissocial disorder, those with limited prosocial emotions tend to display a particularly severe, aggressive and stable pattern of antisocial behaviours. with typical prosocial emotions • In the context of a diagnosis of disruptive behaviour and dissocial disorders, this specifier represents a more common pattern of oppositional defiant disorder or conduct-dissocial disorder that is not characterized by the features of limited prosocial emotions. • Although some features similar to limited prosocial emotions (e.g. low concern, limited remorse) may be evident at times, they are generally infrequent, transitory and less pronounced, and do not represent a persistent pervasive pattern of social-emotional deficits. • Most individuals with disruptive behaviour and dissocial disorders exhibit typical prosocial emotions. 6C9x.y0 6C9x.y1 Disruptive behaviour and dissocial disorders | Conduct-dissocial disorder