Evidence-Based Assessment of DSM-5 Disruptive, Impulse Control, and Conduct Disorders.

The assessment of oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder-the Disruptive, Impulse Control and Conduct Disorders-can be affected by biases in clinical judgment, including overestimating concerns about distinguishing symptoms from normative behavior and stigma associated with diagnosing antisocial behavior. Recent nosological changes call for special attention during assessment to symptom dimensions of limited prosocial emotions and chronic irritability. The present review summarizes best practices for evidence-based assessment of these disorders and discusses tools to identify their symptoms. Despite the focus on disruptive behavior disorders, their high degree of overlap with disruptive mood dysregulation disorder can complicate assessment. Thus, the latter disorder is also included for discussion here. Good practice in the assessment of disruptive behavior disorders involves using several means of information gathering (e.g., clinical interview, standardized rating scales or checklists), ideally via multiple informants (e.g., parent-, teacher-, and self-report). A commitment to providing a full and accurate diagnostic assessment, with careful and attentive reference to diagnostic guidelines, will mitigate concerns regarding biases.

Electroencephalogram-Driven Machine-Learning Scenario for Assessing Impulse Control Disorder Comorbidity in Parkinson's Disease Using a Low-Cost, Custom LEGO-Like Headset.

Patients with Parkinson's disease (PD) may develop cognitive symptoms of impulse control disorders (ICDs) when chronically treated with dopamine agonist (DA) therapy for motor deficits. Motor and cognitive comorbidities critically increase the disability and mortality of the affected patients. This study proposes an electroencephalogram (EEG)-driven machine-learning scenario to automatically assess ICD comorbidity in PD. We employed a classic Go/NoGo task to appraise the capacity of cognitive and motoric inhibition with a low-cost, custom LEGO-like headset to record task-relevant EEG activity. Further, we optimized a support vector machine (SVM) and support vector regression (SVR) pipeline to learn discriminative EEG spectral signatures for the detection of ICD comorbidity and the estimation of ICD severity, respectively. With a dataset of 21 subjects with typical PD, 9 subjects with PD and ICD comorbidity (ICD), and 25 healthy controls (HC), the study results showed that the SVM pipeline differentiated subjects with ICD from subjects with PD with an accuracy of 66.3% and returned an around-chance accuracy of 53.3% for the classification of PD versus HC subjects without the comorbidity concern. Furthermore, the SVR pipeline yielded significantly higher severity scores for the ICD group than for the PD group and resembled the ICD vs. PD distinction according to the clinical questionnaire scores, which was barely replicated by random guessing. Without a commercial, high-precision EEG product, our demonstration may facilitate deploying a wearable computer-aided diagnosis system to assess the risk of DA-triggered cognitive comorbidity in patients with PD in their daily environment.

Laboratory assessment of aggression: The Taylor Aggression Paradigm in adults with and without a disorder of impulsive aggression.

INTRODUCTION: The modified Taylor Aggression Paradigm (TAP) has been used to study impulsive aggression in experimental designs and has been relatively successful in addressing critiques of aggression paradigms; however, little has been done to examine the potential of using the TAP as a direct measure of aggression. This study aimed to explore the psychometric properties of the TAP behavioral indexes as measures of aggression. METHODS: A community sample of 962 adults were divided into three groups based on diagnostic assessments: Intermittent Explosive Disorder; Non-Aggressive Psychiatric Disorder; or healthy controls. Participants then completed the TAP and self-report measures to assess construct validity. A subset of 47 participants completed a second TAP within one year to assess reliability. TAP indexes were based on number of "extreme" shocks selected (high shock index), average shock levels selected (mean shock index), and shocks levels selected without provocation (unprovoked aggression). RESULTS: Overall, TAP indexes were consistent and reliable. IED participants had the highest high shock and mean shock indexes of all groups (X2 = 49.93, p < 0.001). High shock index was related to trait aggression (ß = 0.184, p < 0.001) after including covariates; mean shock index had a trending association with trait anger (ß = 0.102, p = 0.059). CONCLUSION: TAP behavioral indexes demonstrated promising psychometrics as a measure of aggression. High shock index appears to be more strongly associated with aggressive behavior; mean shock index may better measure general hostile responding. Future research might include comparisons specifically with impulse control disorders.

Screening for impulse control disorders in Parkinson's disease and dopamine agonist use: a study of pharmacokinetic and psychological risk factors.

INTRODUCTION: Dopamine agonist (DA) use is considered the main risk factor for impulse control disorder (ICD) development in Parkinson's disease (PD). Besides DAs, personality traits and cognitive features may represent risk factors for ICDs. The primary aim of this study was to investigate differences in DA plasma concentrations in PD patients with and without a positive screening for ICDs according to validated tools. The secondary aim was to compare the psychological profile between ICD positive and negative screened patients. METHODS: PD patients receiving chronic DA therapy were screened for ICDs according to the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). Blood samples for measurement of DA (pramipexole, ropinirole, rotigotine) trough plasma concentrations were drawn in the morning, at mean 16-19 h from the last DA dose. Patients' psychological profile was investigated by Millon Clinical Multiaxal Inventory III and Barratt Impulsiveness Scale (BIS-11). RESULTS: One hundred and five PD patients were enrolled. Forty-one patients (39%) were QUIP positive, mainly for binge eating and hobbyism. Median plasma concentrations of pramipexole (n = 71, 66%), ropinirole (n = 21, 19%), and rotigotine (n = 16, 15%) were similar between QUIP positive and negative patients. QUIP positive patients showed higher motor impulsiveness (p = 0.04) and tended to higher total impulsiveness (p = 0.05). CONCLUSION: This is the first prospective study to evaluate the relationship between DA plasma concentrations and ICDs risk in PD patients. DA plasma levels were overlapping between QUIP positive and negative patients. BIS-11, particularly the motor impulsiveness subscale, might be a useful screening tool in PD patients eligible for DA therapy.

Behavioral excess and disruptive conduct: A historical and taxonomic approach to the origin of the 'impulse control disorders' diagnostic construct.

AIMS: Impulse control disorders (ICDs) are iatrogenic and idiopathic conditions with psychosocial and economic consequences for the affected individuals and their families (e.g. bankruptcy and divorce). However, the definition of ICDs has changed over time, and ICDs are not consistently included within existing taxonomies. We discuss the origins of the ICD diagnostic construct and its unsolved tensions. METHODS: To contextualize the ICD diagnostic construct, we provided an overview of its origins in past centuries and followed its development across multiple editions of the Diagnostic and Statistical Manual and the International Classification of Diseases, as well as its definition within emerging ontologies. RESULTS: Two independent roots of the ICD construct emerged: (a) the interest in behavioral excess as expressed in encyclopedic compilations (18th century) and (b) the juridical debate on disruptive conduct and responsibility (19th-20th centuries). These roots underlie the repeated taxonomic remodeling observed throughout the 20th and 21st centuries and three critical issues persisting in both clinical practice and research. First, the number of ICDs keeps increasing across the spectrum of human behaviors, disregarding common pathogenetic and phenomenological grounds. Secondly, ICDs substantially overlap with other mental conditions. Impulsivity is often neglected as a minor inconvenience or side effect when co-occurring with major diagnoses (e.g. depression) and therefore inadequately managed. Finally, ICDs' definitions display an unsolved tension between being conceived as hobby, moral fault or pathological drive, which may be responsible for stigma and delayed intervention. CONCLUSION: The reasons that made impulse control disorders (ICDs) difficult to define from their first conceptualization are the same reasons that now complicate taxonomic efforts and diagnosis. Tracing back ICDs' roots and criticalities can help to define a common and less ambiguous theoretical framework, which may also result in the demise of the ICD construct and a move towards more clearly defined and more useful ontologies.

Predicting Impulse Control Disorders in Parkinson Disease through Incentive Biomarkers.

OBJECTIVE: This study was undertaken to evaluate whether the feedback-related negativity (FRN)-a neurophysiological marker of incentive processing-can be used to predict the development of impulse control disorders (ICDs) in Parkinson disease (PD). METHODS: The longitudinal cohort consisted of consecutive nondemented PD patients with no ICD history. We recorded FRN signals while they performed a gambling task. We calculated the mean amplitude difference between losses and gains (FRNdiff) to be used as a predictor of future ICD development. We performed prospective biannual follow-up assessments for 30 months to detect incident ICDs. Finally, we evaluated how basal FRNdiff was associated with posterior development of ICDs using survival models. RESULTS: Between October 7, 2015 and December 16, 2016, we screened 120 patients. Among them, 94 patients performed the gambling and 92 completed the follow-up. Eighteen patients developed ICDs during follow-up, whereas 74 remained free of ICDs. Baseline FRNdiff was greater in patients who developed ICDs than in those who did not (-2.33µV vs -0.84µV, p = 0.001). No other significant baseline differences were found. The FRNdiff was significantly associated with ICD development in the survival models both when not adjusted (hazard ratio [HR] = 0.73, 95% confidence interval [CI] = 0.58-0.91, p = 0.006) and when controlling for dopamine replacement therapy, sex, and age (HR = 0.74, 95% CI = 0.55-0.97, p = 0.035). None of the impulsivity measures evaluated was related to ICD development. INTERPRETATION: Reward-processing differences measured by FRN signals precede ICD development in PD. This neurophysiological marker permits identification of patients with high risk of ICD development. ANN NEUROL 2022;92:974-984.

A latent class analysis of intermittent explosive disorder symptoms.

Intermittent explosive disorder (IED), the sole diagnosis in the DSM-5 for which the cardinal symptom is recurrent affective aggressive outbursts, is a common and substantially impairing disorder. IED is also associated with several cognitive and affective impairments. However, little is known about the heterogeneity of the disorder and how this may correspond to aggression severity and related adverse outcomes. The current study employed a latent class analysis (LCA) among individuals diagnosed with lifetime DSM-5 IED to derive distinct subgroups that differed in the quality and/or frequency of cognitive-affective symptoms. These subgroups were then externally validated on a number of adverse outcomes. Statistical and clinical indicators supported a four-class model. Classes were distinguished mainly by the level of emotion dysregulation participants endorsed, with two moderate emotion dysregulation classes differing on their emotional information processing and impulsive tendencies. The external validation analysis revealed that classes differed in terms of various adverse outcomes (e.g., interpersonal problems, life satisfaction, suicide risk). Overall, the present study suggests distinct cognitiveaffective symptom profiles among those with IED that differ meaningfully with regard to risk for adverse outcomes. These findings provide evidence of the heterogeneity within IED and may suggest a more personalized therapeutic approach to patients with IED.

Assessment of subjective sleep quality and issues in aggression: Intermittent Explosive Disorder compared with psychiatric and healthy controls.

BACKGROUND: While prior research has linked clinical sleep issues and aggression, little is known about how clinical sleep issues among individuals with Intermittent Explosive Disorder (IED), which is characterized by a pervasive pattern of impulsive aggression and associated with consequences across multiple life-domains. The present study aims to examine clinical sleep issues among individuals with IED in contrast to individuals with other psychopathology and healthy controls. METHODS: 257 adults, including 100 healthy controls, 85 psychiatric controls and 72 individuals with IED, took part in this study. Participants completed the Structured Clinical Interview for DSM-V Diagnoses, Assessment of clinical sleep issues included the Pittsburgh Sleep Quality Inventory (PSQI), obstructive sleep apnea (OSA) screening, and the Epworth Sleepiness Scale (ESS) as well as assessments of aggression and impulsivity. RESULTS: IED study participants reported significantly worse sleep quality, increased sleep latency, greater daytime sleepiness and symptoms of OSA. Daytime sleepiness and sleep quality was correlated with impulsivity and aggression. CONCLUSIONS: This study suggests that individuals with IED have clinically relevant sleep anomalies, and that these are directly associated with measures of impulsivity and aggression. Clinicians treating aggressive individuals are advised to assess and treat such individuals for sleep issues.

Adaptation and validation of a German version of the Dickman impulsivity inventory for the assessment of functional and dysfunctional impulsivity.

Impulsive behavior tends to have a negative connotation in the sense that it is usually associated with detrimental or dysfunctional outcomes. However, under certain circumstances, impulsive behaviors may also have beneficial or functional outcomes. Dickman's Impulsivity Inventory (DII) measures these two distinct aspects of impulsivity, namely, dysfunctional impulsivity (the tendency to act with less forethought than do most people which leads to difficulties) and functional impulsivity (the tendency to act with little forethought when the situation is optimal). In the present study, we translated the DII into German and validated the German version in a sample of 543 adults. The original 23-item model was considered unsuitable for the German version as suggested by fit indices of a confirmatory factor analysis. Exploratory factor analyses rather supported a 16-item version. Further psychometric analyses and inferential statistical analyses on the final German DII indicated its appropriateness for use in German-speaking populations and support a two-factor solution of the DII. Finally, exploratory analyses on the German DII suggest differential relationships between dysfunctional and functional impulsivity and self-reported lifestyle-related variables (smoking, alcohol usage, and sports behavior).

Prolactinomas.

Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are the main pathological cause. Prolactinomas lead to signs and symptoms of hormone oversecretion, such as galactorrhea and hypogonadism, as well as symptoms of mass effect, including visual impairment, headaches and intracranial hypertension. Diagnosis involves prolactin measurement and sellar imaging, but several pitfalls are involved in this evaluation, which may difficult the proper management. Treatment is medical in the majority of cases, consisting of dopamine agonists, which present high response rates, with a very favorable safety profile. Major adverse effects that should be monitored consist of cardiac valvulopathy and impulse control disorders. Other treatment options include surgery and radiotherapy. Temozolomide may be used for aggressive or malignant carcinomas. Finally, pregnancy outcomes are similar to general population even when dopamine agonist treatment is maintained.

Objective assessment of impulse control disorder in patients with Parkinson's disease using a low-cost LEGO-like EEG headset: a feasibility study.

BACKGROUND: Patients with Parkinson's disease (PD) can develop impulse control disorders (ICDs) while undergoing a pharmacological treatment for motor control dysfunctions with a dopamine agonist (DA). Conventional clinical interviews or questionnaires can be biased and may not accurately diagnose at the early stage. A wearable electroencephalogram (EEG)-sensing headset paired with an examination procedure can be a potential user-friendly method to explore ICD-related signatures that can detect its early signs and progression by reflecting brain activity. METHODS: A stereotypical Go/NoGo test that targets impulse inhibition was performed on 59 individuals, including healthy controls, patients with PD, and patients with PD diagnosed by ICDs. We conducted two Go/NoGo sessions before and after the DA-pharmacological treatment for the PD and ICD groups. A low-cost LEGO-like EEG headset was used to record concurrent EEG signals. Then, we used the event-related potential (ERP) analytical framework to explore ICD-related EEG abnormalities after DA treatment. RESULTS: After the DA treatment, only the ICD-diagnosed PD patients made more behavioral errors and tended to exhibit the deterioration for the NoGo N2 and P3 peak amplitudes at fronto-central electrodes in contrast to the HC and PD groups. Particularly, the extent of the diminished NoGo-N2 amplitude was prone to be modulated by the ICD scores at Fz with marginal statistical significance (r = - 0.34, p = 0.07). CONCLUSIONS: The low-cost LEGO-like EEG headset successfully captured ERP waveforms and objectively assessed ICD in patients with PD undergoing DA treatment. This objective neuro-evidence could provide complementary information to conventional clinical scales used to diagnose ICD adverse effects.

Elevated Mood States in Patients With Parkinson's Disease Treated With Deep Brain Stimulation: Diagnosis and Management Strategies.

OBJECTIVE: Deep brain stimulation (DBS) is an effective surgical treatment for patients with Parkinson's disease (PD). DBS therapy, particularly with the subthalamic nucleus (STN) target, has been linked to rare psychiatric complications, including depression, impulsivity, irritability, and suicidality. Stimulation-induced elevated mood states can also occur. These episodes rarely meet DSM-5 criteria for mania or hypomania. METHODS: The investigators conducted a chart review of 82 patients with PD treated with DBS. RESULTS: Nine (11%) patients developed stimulation-induced elevated mood. Five illustrative cases are described (all males with STN DBS; mean age=62.2 years [SD=10.5], mean PD duration=8.6 years [SD=1.6]). Elevated mood states occurred during or shortly after programming changes, when more ventral contacts were used (typically in monopolar mode) and lasted minutes to months. Four patients experienced elevated mood at low amplitudes (1.0 V/1.0 mA); all had psychiatric risk factors (history of impulse-control disorder, dopamine dysregulation syndrome, substance use disorder, and/or bipolar diathesis) that likely contributed to mood destabilization. CONCLUSIONS: Preoperative DBS evaluations should include a thorough assessment of psychiatric risk factors. The term "stimulation-induced elevated mood states" is proposed to describe episodes of elevated, expansive, or irritable mood and psychomotor agitation that occur during or shortly after DBS programming changes and may be associated with increased goal-directed activity, impulsivity, grandiosity, pressured speech, flight of ideas, or decreased need for sleep and may persist beyond stimulation adjustments. This clinical phenomenon should be considered for inclusion in the bipolar disorder category in future DSM revisions, allowing for increased recognition and appropriate management.

Emotion attribution in intermittent explosive disorder.

BACKGROUND: Accurate recognition of the emotions of others is an important part of healthy neurological development and promotes positive psychosocial adaptation. Differences in emotional recognition may be associated with the presence of emotional biases and can alter one's perception, thus influencing their overall social cognition abilities. The present study aims to extend our collective understanding of emotion attribution abnormalities in individuals with Intermittent Explosive Disorder (IED). METHODS: Two-hundred and forty-two adults participated, separated into groups of those diagnosed with IED according to DSM 5 criteria, Psychiatric Controls (PC), and Healthy Controls (HC). Participants completed a modified version of the Emotional Attribution Task wherein they attributed an emotion to the main character of a short vignette. RESULTS: Participants with IED correctly identified anger stories and misattributed anger to non-anger stories significantly more often than PC and HC participants. They were also significantly less likely than HC participants to correctly identify "sad stories." LIMITATIONS: We utilized self-report assessments in a community-recruited sample. Replication in a clinical is suggested. CONCLUSIONS: Findings from this study support the validity of IED as a diagnostic entity and provide important information about how individuals with psychiatric disorders perceive and experience emotional cues.

The relationship between exposure to general anesthetic agents and the risk of developing an impulse control disorder.

Most studies examining the effect of extended exposure to general anesthetic agents (GAAs) have demonstrated that extended exposure induces both structural and functional changes in the central nervous system. These changes are frequently accompanied by neurobehavioral changes that include impulse control disorders that are generally characterized by deficits in behavioral inhibition and executive function. In this review, we will.

Consideration of Clinician and Researcher Opinions on the Parameters of Nonsuicidal Self-Injury Disorder Diagnostic Criteria.

Nonsuicidal self-injury (NSSI) disorder represents an opportunity to address the significant costs associated with NSSI; however, there is a need to resolve the uncertainty regarding specific parameters of the diagnostic criteria to ensure clinical utility. As such, to better understand the clinical applicability, and guide future research in this area, clinicians and researchers in the field of NSSI (n=112) completed an anonymous online survey assessing their opinions regarding several aspects of NSSI disorder. Results highlight that past-month NSSI was the most frequently endorsed timeframe required for a NSSI disorder diagnosis. There was support for the clinical usefulness of several specifiers and general consensus regarding exclusion criterion. Finally, Disruptive, Impulse-Control and Conduct Disorders was considered to be the most appropriate diagnostic category. Our findings suggest that requiring four days of NSSI in the past one-month may enhance the clinical utility of NSSI disorder. Results also offer guidance on additional aspects of the diagnostic criteria to better describe and conceptualize NSSI disorder for research and clinical applications.

Prevalence and psychiatric comorbidities of intermittent explosive disorders in Metropolitan São Paulo, Brazil.

PURPOSE: To estimate the prevalence of intermittent explosive disorder (IED) in comorbidity with other psychiatric disorders and to describe the temporal sequencing of disorders in the São Paulo Metropolitan Area, Brazil. METHODS: Data from the São Paulo Megacity Mental Health Survey, a population-based study of 5037 adult individuals, were analyzed. The World Health Organization Composite International Diagnostic Interview (CID 3.0) was used to assess lifetime DSM-IV disorders, including IED, with a response rate of 81.3%. RESULTS: The majority (76.8%) of respondents with IED meet the criteria for at least one other psychiatric disorder, with a prevalence almost twice as high as that observed in individuals without IED. The prevalence of any anxiety, mood, impulse control or substance use disorders in respondents with IED was more than two times higher compared to those without IED, with prevalence ratios ranging from 2.1 (95% CI 1.74-2.48) to 2.9 (95% CI 2.12-4.06). The diagnosis of IED occurred earlier than most of the other mental disorders, except for those with usual onset in early childhood, as Specific and Social Phobias and Attention Deficit Disorder. CONCLUSION: Considering that IED is a highly comorbid disorder and has an earlier onset than most other mental comorbidities in the Brazilian general population, these results may be useful in guiding governmental mental health actions.

Evidence for the taxonic latent structure for DSM-5 intermittent explosive disorder in adults.

BACKGROUND: Identification of individuals with clinically significant aggressive behavior is critical for the prevention and management of human aggressive behavior. A previous population-based taxometric study reported that the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV) intermittent explosive disorder (IED) belongs to its own discrete class (taxon) rather than existing along a continuum. METHODS: This study sought to extend previous population-based findings in a clinical research sample of adults with DSM-5 IED (n = 346), adults with non-aggressive DSM-5 disorders (n = 293), and adults without any DSM-5 disorder (n = 174), using standardized assessments of DSM-5 diagnoses, aggression, and other related measures not available in past studies. RESULTS: Analyses revealed a taxonic latent structure that overlapped with the DSM-5 diagnosis of IED. Within the sample, taxon group members had higher scores on a variety of measures of psychopathology than did the complement members of the sample. Comorbidity of other diagnoses with IED did not affect these results. CONCLUSION: These findings support the proposition that DSM-5 IED represents a distinct behavioral disorder rather than the severe end of an aggressive behavior continuum.

Differentiating irritable mood and disruptive behavior in adults.

INTRODUCTION: Irritability has both mood and behavioral manifestations. These frequently co-occur, and it is unclear to what extent they are dissociable domains. We used confirmatory factor analysis and external validators to investigate the independence of mood and behavioral components of irritability. METHODS: The sample comprised 246 patients (mean age 45 years; 63% female) from four outpatient programs (depression, anxiety, bipolar, and schizophrenia) at a tertiary hospital. A clinical instrument rated by trained clinicians was specifically designed to capture irritable mood and disruptive behavior dimensionally, as well as current categorical diagnoses i.e., intermittent explosive disorder (IED); oppositional defiant disorder (ODD); and an adaptation to diagnose disruptive mood dysregulation disorder (DMDD) in adults. Confirmatory factor analysis (CFA) was used to test the best fitting irritability models and regression analyses were used to investigate associations with external validators. RESULTS: Irritable mood and disruptive behavior were both frequent, but diagnoses of disruptive syndromes were rare (IED, 8%; ODD, 2%; DMDD, 2%). A correlated model with two dimensions, and a bifactor model with one general dimension and two specific dimensions (mood and behavior) both had good fit indices. The correlated model had root mean square error of approximation (RMSEA) = 0.077, with 90% confidence interval (90%CI) = 0.071-0.083; comparative fit index (CFI) = 0.99; and Tucker-Lewis index (TLI) = 0.99, while the bifactor model had RMSEA = 0.041; CFI = 0.99; and TLI = 0.99 respectively). In the bifactor model, external validity for differentiation of the mood and behavioral components of irritability was also supported by associations between irritable mood and impairment and clinical measures of depression and mania, which were not associated with disruptive behavior. CONCLUSIONS: Psychometric and external validity data suggest both overlapping and specific features of the mood vs. disruptive behavior dimensions of irritability.