A woman brings her 17-year-old son to the office for evaluation of his behavior. She reports that he is failing most of his classes despite being smart, and she is worried he will not graduate from high school. He has skipped school regularly since the sixth grade and frequently lies to his mother about his whereabouts. The patient says his teachers are not as smart as he is, and he refuses to do any homework because it is a "waste of time." He has been suspended several times for fighting and was once caught stealing a wallet from the teachers' lounge. The patient uses alcohol and marijuana but is unwilling to say how often. He has tried cocaine but feels it made him "too hyper." His mother reports he often stays out past curfew and has come home intoxicated a few times. The patient sits in an exaggerated slump and appears annoyed about being brought to the appointment. He argues with his mother throughout the evaluation, and his responses to the physician are short and sarcastic. Which of the following is the most likely explanation for the patient's behavior?

Question

A woman brings her 17-year-old son to the office for evaluation of his behavior.  She reports that he is failing most of his classes despite being smart, and she is worried he will not graduate from high school.  He has skipped school regularly since the sixth grade and frequently lies to his mother about his whereabouts.  The patient says his teachers are not as smart as he is, and he refuses to do any homework because it is a "waste of time."  He has been suspended several times for fighting and was once caught stealing a wallet from the teachers' lounge.  The patient uses alcohol and marijuana but is unwilling to say how often.  He has tried cocaine but feels it made him "too hyper."  His mother reports he often stays out past curfew and has come home intoxicated a few times.  The patient sits in an exaggerated slump and appears annoyed about being brought to the appointment.  He argues with his mother throughout the evaluation, and his responses to the physician are short and sarcastic.  Which of the following is the most likely explanation for the patient's behavior?

Quizplus · Accepted Answer

11ec25c8_d7b1_2381_bc81_b9424e2fb9aa_MD0003_00 This patient's persistent pattern of lying, truancy, stealing, and fighting is most consistent with conduct disorder (CD). CD is a childhood psychiatric disorder characterized by behaviors that violate societal norms appropriate to the patient's age (eg, excessive absenteeism, consistently staying out past curfew) or the rights of others (eg, often initiating fights). Other behaviors seen in CD include bullying, using weapons (eg, broken bottle, bat, gun, knife), torturing animals, setting fires, destroying property, and forcing others into sexual activity. These conducts impact functioning (eg, not graduating from high school). CD generally presents in middle childhood to adolescence and is more common in boys. Adolescents with CD are at greater risk for developing antisocial personality disorder as adults. Individuals must be age ≥18 to receive a diagnosis of antisocial personality disorder and must have evidence of CD before age 15 (Choice A). (Choice C) Individuals with intermittent explosive disorder also have episodes of aggression. However, they do not have other features seen in CD (eg, deceit, theft, truancy), and their behavior is not premeditated or intended to defy rules or gain advantage over others. (Choice D) In narcissistic personality disorder, grandiosity is related to the need to be the center of attention and admired. Individuals with narcissistic personality disorder do not display a pattern of violating social norms or the rights of others, as seen in CD. (Choice E) Oppositional defiant disorder is characterized by a pattern of angry/irritable mood and argumentative/defiant behavior toward authority figures. Compared to CD, the symptoms of oppositional defiant disorder are less severe and do not include stealing or aggressive violations of the rights of others. This patient's history of repeated fighting, stealing, and lying is more consistent with CD. (Choice F) Effects of substance use should always be considered in adolescents with behavior problems and/or mood disturbances. Although substance use might be related to stealing, irritability, and poor school performance, this patient's persistent pattern of violating major societal norms and the rights of others in multiple settings makes CD the more likely explanation for his behavior. Educational objective: Conduct disorder is characterized by a repetitive pattern of violating basic social norms and the rights of others. Common manifestations include truancy, lying for gain or to avoid repercussions, and initiating physical fights with others. References: Conduct disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23224151) Evaluation of the known behavioral heterogeneity in conduct disorder to improve its assessment and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24889762)

A Woman Brings Her 17-Year-Old Son to the Office for Evaluation