Review Question - QID 108413

This patient is suffering from classic symptoms of conduct disorder. The patient defies authority figures, is violent, and is even seen stealing. Since he is younger than 18 years of age the diagnosis is conduct disorder, and there is a likely progression to antisocial personality disorder when he turns 18.

Conduct disorder can be thought of as equivalent to antisocial personality disorder with the exception that conduct disorder occurs before the age of 18, and antisocial personality disorder is diagnosed at the age of 18 or later. Both disorders are characterized by violation of societal norms and the basic humanity of others. Theft, dishonesty, violence, and law-breaking are very classic behaviors seen in these individuals. They do not demonstrate remorse for their behavior, and this personality disorder is most commonly associated with criminals.

This patient is aggressive and has behavior that violates the norms of society thus the first diagnosis that should jump to mind is antisocial personality disorder. Given that this patient is a child, it is important to remember that the equivalent diagnosis is conduct disorder because antisocial personality disorder can only be diagnosed after age 18. Going forward it is important to notice some of the other potential causes of this patient's symptoms. A child that lives in a pre-war house could be exposed to lead. Lead exposure could explain this child's symptoms and would be the correct answer had his blood lead level been elevated. The patient's urine toxicology was also negative ruling out other potential intoxications as the cause.

Incorrect Answers:
Answer 1: This patient will likely continue to defy authority figures though will otherwise function fine in society is characteristic of oppositional defiant disorder. Oppositional defiant disorder is characterized by behavior that is argumentative and contrary to authority figures, though these individuals do follow cultural and moral rules. This patient's criminal behavior (hurting animals, etc.) makes this answer incorrect.
Answer 2: This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood is incorrect based only on a technicality; you cannot make the diagnosis of antisocial personality disorder until the patient is 18 years of age. Until then the diagnosis is conduct disorder. This difference is important and it is important to note the patient's age.
Answer 3: Environmental exposures (living in an old house) causing these behaviors (aggression and abnormal behavior) would be possible with lead intoxication. The most accurate test is a blood lead level, which in this case is extremely low/undetectable, suggesting that this patient has not been exposed to lead. High yield associations with lead intoxication are inhibition of ferrochelatase, increased zinc protoprophyrin, microcytic anemia, aggression, Mee's lines of the fingernails, darkening of the ginivae (black lines), hyper-dense lead lines on radiographs of bones and exposure to old buildings and paint.
Answer 5: Strong D2 antagonists such as haloperidol and fluphenazine are not the correct management of personality disorders such as antisocial personality or conduct disorder. These drugs are appropriate in psychosis, schizophrenia, acute intoxication with PCP and other psychotic disorders and episodes. Personality disorders tend to be managed with CBT.

There are many important demographic factors associated with conduct disorder. Of note, parental substance abuse, low socioeconomic status, and oppositional behavior are some of the most prominent predictive factors (1). It is important to be aware of these epidemiological factors in particular for Step exams.