Impulse control disorder

1. IMPULSE CONTROL
DISORDERS
P R E S E N T E R – D R S I R I
C H A I R P E R S O N – D R S I VA B A C K I YA

2. OVERVIEW
• Introduction
• Etiology
• Epidemiology
• Disorders
• Criteria
• Differential Diagnosis
• Course and Prognosis
• Treatment

3. INTRODUCTION
• Impulsivity is a trait ubiquitous with human nature.
• What separates humans from life forms of lower sentience is the evolution of
neurocircuitry within the prefrontal cortex that allows one to practice self-
governance.
• Self-regulation arises from the existence of a conflict between two mutually
exclusive inner psychic agencies, or more descriptively in Freudian terminology,
between the impulsive id and the captious superego.

4. • The disorders encompassed within impulse control disorder (ICD) are identified as externalizing
disorders, as these individuals express hostility and resentment externally, made manifest by conflicts
with others.
• Patients will often reveal a history of physical or verbal abuse towards others, representing underlying
impaired inhibition.
• Providers will unveil an evolving tension transpiring just before the deviance, followed by subsequent
relief and catharsis.
• Most importantly, these behavior patterns are extreme and inappropriate when contrasted with those of
similar biological and developmental age, resulting in severe psychosocial and functional impairments.

5. ETIOLOGY
• Origin is multifactorial.
• Genetics may play a pertinent role as children with ODD are often the progeny of
parents with mood disorders
• Those with CD spawn from parents who have schizophrenia, ADHD, substance use
disorder, or antisocial personality disorders.
• Social factors - low socioeconomic status, community violence, lack of structure,
neglect, abusive environment, and deviant peer relations.
• Biological disturbances - reduced basal cortisol activity and functional abnormalities
in frontotemporal-limbic circuits.
• Cognitive deficits act as antecedents to ICD, such as learning disabilities.

6. EPIDEMIOLOGY
• Epidemiologists estimate the prevalence of oppositional defiant disorder (ODD),
conduct disorder (CD), intermittent explosive disorder (IED), concomitant ODD
and CD, and kleptomania to be 3.3%, 4%, 2.7%, 3.5% and 0.6%, respectively.
• Pyromania has proven rarer than its other impulse control disorder (ICD)
counterparts.
• Most ICD diagnoses occur more frequently in boys than girls, besides
kleptomania, which occurs three times more frequently in females.
• ODD has the greatest incidence before adolescence, whereas CD peaks in middle
adolescence.
• IED tends to vary more greatly, but studies suggest persons are usually younger
than 35 to 40 years old.

7. NEUROBIOLOGY
• Disordered monoamine neurotransmission has been implicated in the
pathophysiology of ICD.
• Three main neurotransmitter systems
1) serotonin (5-HT) function in the initiation and cessation of the problematic
behaviour.
2) Abnormal dopamine (DA) function contributing to modulation of reward and
reinforcement pathways, particularly with regard to aggressive and other
impulsive behaviour.
3) norepinephrine (NE) dysfunction associated with arousal and excitement.

8. OPPOSITIONAL DEFIANT DISORDER

9. ODD
• Oppositional defiant disorder (ODD) - primarily involves problems with the self-control of
emotions and behaviors.
• According to (DSM-5), the main feature of ODD is a persistent pattern of angry or irritable
mood, argumentative or defiant behavior, or vindictiveness toward others.
• Etiology :
• Gene-environment interactions also appear to be significant in the development of ODD.
• Low activity level of the neurotransmitter-metabolizing enzyme monoamine oxidase A (MAO-A)
• Changes in cortisol levels.

10. Epidemiology :
• ODD is more common in preadolescent males than in females (1.4 :1)
• Prevalence - 2% to 11%.
• Diagnosis : DSM-5
At least four symptoms from the list below should have been present on most days for at least 6
months demonstrating a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness:
1. Often loses temper
2. Often touchy or easily annoyed
3. Often angry and resentful
4. Often argue with authority figures or, for children and adolescents, with adults
5. Often actively refuse or defy to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or misbehavior
8. The child has been spiteful or vindictive at least twice within the past 6 months

11. Assessment tools :
• The Child Behaviour Checklist
• Conners Child Behaviour Checklist
• The Behaviour Assessment for Children (BASC - 2)
• Strength and Difficulties Questionnaire (SDQ)
• The Child and Adolescent Psychiatric Assessment

12. MANAGEMENT
Non-Pharmacological management :
• Parent management training, school-based interventions, individual child therapy, and family
therapy. Additionally, identification of attachment security, parent-child relationships,
Pharmacological :
- Treatment of comorbidities.
- Risperidone has the best evidence for control of aggressive behaviors, followed by
aripiprazole,While quetiapine has been observed to alleviate aggression.
- Stimulants, including methylphenidate, are helpful in cases of comorbid ADHD, and non-
stimulants such as atomoxetine, guanfacine, and clonidine also have beneficial effects.

13. CONDUCT
DISORDER

14. CONDUCT DISORDER
• Conduct disorder is defined as the persistent and repetitive violation of major societal
norms and the basic rights of others.
• For a diagnosis of CD, the child should have at least three symptoms in the past 12
months from the following domains - aggression to people and animals, destruction of
property, deceitfulness or theft, and serious violations of rules.
• Symptoms include bullying, threatening, initiating physical fights, cruelty to animals
and others, forcing others into sexual activity, destroying property, stealing and
breaking into a house or car, etc.

15. • The diagnosis of CD does not automatically transform into antisocial personality disorder at age
18.
• History - The quintessential feature of conduct disorder (CD) is a persistent violation of social
rules and the rights of others.
• Additional salient features include the destruction of property, deceitfulness, and illegal activity.
• Those with CD have often been characterized as callous, manipulative, and unemotional.

16. • Etiology : Evidence for low levels of plasma dopamine beta-hydroxylase supports the finding
of decreased activity of the noradrenergic system in the CD.
• Low levels of 5-Hydroxy Indole acetic acid (5-HIAA) levels in CSF correlate with aggression
and violence in adolescence.
• Epidemiology : common in boys than girls, ratio could range from 4:1 as much as 12:1.
• The lifetime prevalence rate in the general population could range from anywhere between 2 to
10% and is consistent among different race and ethnic groups.

17. TYPES
CD, Childhood-Onset Type
• The onset of problems before age ten
• More common in males
• More physical aggression, Worse prognosis
CD, Adolescent-Onset Type
• Lack of problems before age ten
• Less physical aggression, better prognosis
CD, Unspecified-Onset Type
• Age of onset is unknown

18. EVALUATION
• Complete psychiatric assessment with appropriate history taking for uncovering psychiatric
comorbidities like ADHD, Mood disorders
• Assessment should be made in multiple settings with proper collateral information from
school families and other significant caregivers.
• Thorough academic assessment with uncovering difficulties in the school environment with
possible learning disorders
• Functional behavioral analysis of the patterns of repetitive behaviors and understanding
complex family dynamics.

19. TREATMENT
Evidence-based Psychosocial Treatments
• Parent management training, Multisystemic therapy
• Anger management training
• Individual psychotherapy
• Community-based treatment
Pharmacotherapy
• Targets treating psychiatric comorbidities with appropriate medications such as stimulants and
non-stimulants for the treatment of ADHD, antidepressants for the treatment of depression, mood
stabilizers for the treatment of aggression, mood dysregulation, and bipolar disorder
• Mood stabilizers include conventional mood stabilizers like AEDs (antiepileptic drugs) and
second-generation antipsychotics.

20. INTERMITTENT
EXPLOSIVE
DISORDER

21. CLINICAL PRESENTATION
• Patients with intermittent explosive disorder have discrete episodes of losing
control of their aggressive impulses; these episodes can result in severe assault
or the destruction of property.
• The aggressiveness expressed is grossly out of proportion to any stressors that
may have helped elicit the events. The episodes appear within minutes or hours
and, regardless of duration, remit spontaneously and quickly.
• After each episode, patients usually show genuine regret or guilt, and signs of
generalized impulsivity or aggressiveness are absent between events.
• Clinicians should not diagnose intermittent explosive disorder if they can better
explain the symptoms with another disorder.

22. • Intermittent explosive disorder (IED) is defined as a low tolerance for
frustration and adversity.
• Between explosive episodes, patients will demonstrate appropriate behavior;
however, upon exposure to minimal adversity, these patients will respond with
violent, disproportionate tantrums, which may seem “out of character.”
• The explosive outbursts have no impetus for secondary gain.

25. DIAGNOSIS
• The diagnosis of intermittent explosive disorder should be the result of
history-taking that reveals several episodes of loss of control associated
with aggressive outbursts.
• One discrete episode does not justify the diagnosis.
• The histories typically describe a childhood in an atmosphere of an
alcohol use disorder, violence, and emotional instability.
• Patients’ work histories are poor; they report job losses, marital
difficulties, and trouble with the law.
• Most patients have sought psychiatric help in the past.
• Anxiety, guilt, and depression usually follow an outburst, but this is not
a constant finding.

26. DIFFERENTIAL DIAGNOSIS
- Psychotic disorders
- Personality change because of a general medical condition
- Antisocial or borderline personality disorder
- Substance intoxication (e.g., alcohol, barbiturates, hallucinogens,
amphetamines)
- Epilepsy, brain tumors, degenerative diseases, and endocrine disorders.

27. ETIOLOGY
• Childhood exposure to violence, maltreatment, and neglect.
• Prefrontal cortical dysfunction has been associated with impulsive aggression. Some
investigators suggest that disordered brain physiology, particularly in the limbic system,
is involved in most cases of episodic violence.
• Low levels of CSF 5-hydroxyindoleacetic acid (5-HIAA) correlate with violent suicide
attempts and impulsive aggression in some studies.
• High CSF testosterone concentrations are associated with aggressiveness and
interpersonal violence in men. Antiandrogenic agents have been shown to decrease
aggression.
• Evidence indicates that intermittent explosive disorder is more common in first-degree
biologic relatives of persons with the disorder than in the general population.

28. CO-MORBID CONDITIONS
• More than 80 percent of individuals with intermittent explosive disorder meet
the criteria for another psychiatric disorder.
• These include other disorders of impulse-control and substance use, and
mood, anxiety, personality (antisocial and borderline), posttraumatic stress, and
eating disorders.
• Also, individuals with intermittent explosive disorder have been reported to be
at increased risk of self-harm.

29. COURSE AND PROGNOSIS
• Intermittent explosive disorder may begin at any stage of life but usually
appears between late adolescence and early adulthood.
• The onset can be sudden or insidious, and the course can be episodic or
chronic.
• In most cases, the disorder decreases in severity with the start of middle
age, but heightened organic impairment can lead to frequent and severe
episodes.
• Intermittent explosive disorder is more common in men than women.

30. TREATMENT
• Pharmacotherapy has been a mainstay of the treatment of aggressive
behavior.
• SSRIs, mood stabilizers and antipsychotic drugs.
• Lithium has been reported useful in generally lessening aggressive
behavior, and carbamazepine, valproate, and phenytoin have been
reported helpful. Some clinicians have also used other anticonvulsants
(e.g., topiramate).
• Placebo-controlled trials showed that valproate and divalproex
significantly reduce aggressive acts in individuals with personality
disorders and conduct disorder.

31. TREATMENT
• Elderly patients with dementia - at doses of 0.8 to 2.0 mg/day, risperidone has shown
efficacy at reducing aggression and agitation and is generally well tolerated.
• Methylphenidate - effective at reducing impulsive aggression in conduct disorder and
ADHD.
• Use of benzodiazepines can cause disinhibition, thus worsening the behaviors.

32. TREATMENT
Psychotherapy :
Group psychotherapy may be helpful, and family therapy is useful,
especially when the explosive patient is an adolescent or a young adult.
A goal of treatment is to have the patient recognize and verbalize the
thoughts or feelings that precede the explosive outbursts instead of acting
them out.
Cognitive-behavioral therapy and contingency management may be
helpful.

33. PYROMANIA
• Pyromania is defined as recurrent failure to refrain from
impulsive fire setting.
• There is a heightened tension before firesetting and after
firesetting.
• The fire setting is not in the context of anger, improving living
conditions. The arson is not better explained by CD, mania, or
antisocial personality disorder.
• Patients with pyromania engender pleasure in the setting of
fires, as well as in the observance of the aftermath.
• This could be an expression of impulsive behavior without a
secondary gain.

34. CLINICAL PRESENTATION
• Patients with pyromania repeatedly and deliberately set fires.
• They feel an urge to do this and relief or pleasure after they do. They
typically are fascinated with all aspects of fires and may set off false
alarms.
• They often are attracted to firefighting, may spend time at their local fire
department, volunteer, or even become professional firefighters.
• Their curiosity is evident, but they show no remorse and may be
indifferent to the consequences for life or property.
• Fire-setters may gain satisfaction from the resulting destruction;
frequently, they leave apparent clues.
• It is important to differentiate pyromania from other causes of fire setting

36. ETIOLOGY
• Freud described pyromania as consequence of abnormal psychosexual development.
• Neurobiology - Studies suggest that pyromania may be associated with lower
concentration of norepinephrine and serotonin metabolites 3-methoxy-4-
hydroxyphenylglycol (MHPG) and 5- hydroxyindoleacetic acid (5-HIAA).
• A single case report found a perfusion deficit in the left inferior frontal lobe on Single-
photon emission tomography (SPECT), which resolved after treatment with cognitive-
behavioral therapy (CBT) and topiramate.

37. DIFFERENTIAL DIAGNOSIS
• Clinicians should have little trouble distinguishing between pyromania
and the fascination of many young children with matches, lighters, and
fire as part of the normal investigation of their environments.
• When a fire setting occurs in conduct disorder and antisocial personality
disorder, it is a deliberate act, not a failure to resist an impulse.
• Patients with schizophrenia or mania may set fires in response to
delusions or hallucinations.
• Patients with brain dysfunction (e.g., dementia), mental retardation, or
substance intoxication may set fires because of a failure to appreciate the
consequences of the act.

38. CO-MORBID CONDITIONS
• Substance use disorders (especially alcohol and marijuana use
disorders)
• Affective disorders, depressive or bipolar, and other impulse-control
disorders.
• They are also reported to have increased suicidal thought.

39. COURSE AND PROGNOSIS
• It should not be too surprising that we know very little about the development
and course of pyromania.
• Most individuals with pyromania start setting fires in adolescence or young
adulthood.
• The frequency and intensity of fire setting may increase over time or may wax
and wane.
• The course of pyromania is unknown, but smaller studies suggest it may be
chronic.
• Pyromania occurs more frequently in males with weaker social skills and
learning difficulties.

40. TREATMENT
• Some case reports have shown a reduction in pyromania urges and behaviors with
SSRIs, lithium, naltrexone, stimulants, topiramate, valproic acid, carbamazepine, anti-
androgen medication, clonazepam, and olanzapine.
• CBT was the most efficacious in reducing fire setting, interest in playing with matches,
and fire-related behaviors.
• Other successful behavioral therapies for fire setting include aversive therapy,
education, relaxation techniques, positive reinforcement, graphing therapy, and fire
safety education.
• In the case of children and adolescents, treatment of pyromania or fire setting should
include family therapy.

41. KLEPTOMANIA
Kleptomania is defined as the recurrent urges to steal objects with no
monetary value. There is a heightened tension before committing the theft
and relief after committing the theft. These acts of stealing do not occur
during a hallucination or a delusion or mania or conduct disorder.
Patients with kleptomania experience a similar urge to
pyromaniacs and will steal “unnecessary” items of trivial to no
value. Patients with kleptomania often ascribe limited value to
the items they steal and may discard the stolen goods or even
return them. This disorder is most commonly seen in females.

42. CLINICAL PRESENTATION
• Patients with kleptomania (from the Greek kleptēs, “thief”)
describe a recurrent failure to resist the impulse to steal
objects, even though they have no need for the objects.
• The goal is not to obtain a specific item, it is the act of
stealing itself.
• Experience mounting tension before the act, followed by
gratification and lessening of tension after the action.
• They may or may not feel guilt or remorse and might feel
depressed about their behavior.
• The theft is not planned and does not involve others.

44. ASSESMENT
- Kleptomania is associated with increased impulsivity, with a study showing that patients
with kleptomania had higher scores on the Barratt Impulsiveness Scale, greater cognitive
impulsivity, and greater sensation seeking in comparison to a psychiatric group.
- Individuals with a greater severity of kleptomania symptoms have been shown to
demonstrate more executive functioning impairment on the Wisconsin Card Sorting Test
(WCST), greater cognitive impulsivity, and greater sensation seeking.

45. DIFFERENTIAL DIAGNOSIS
• Shoplifting has become a national epidemic. Few shoplifters have true kleptomania; most are
teenagers and young adults who steal in pairs or small groups for “kicks” as well as goods and do not
have a psychiatric disorder.
• Individuals with an antisocial personality disorder steal for personal gain, with some degree of
premeditation and planning. Often they convince others to rob for them. Antisocial stealing regularly
involves the threat of harm or actual violence, mainly to elude capture. Guilt and remorse are
distinctively lacking, or patients are patently insincere.
• Episodes of theft occasionally occur during psychotic illness, for example, acute mania, major
depression with psychotic features, or schizophrenia. Psychotic stealing is a product of pathologic
elevation or depression of mood or command hallucinations or delusions.
• Acute intoxication with drugs or alcohol may precipitate theft in an individual with another psychiatric
disorder or without significant psychopathology. Patients with Alzheimer disease or other dementing

46. • organic illness may leave a store without paying, owing to forgetfulness rather than
larcenous intent.
• Some individuals with an antisocial personality disorder or no disorder may steal and
then claim to suffer from kleptomania. This would be an example of malingering, not
kleptomania, although with sufficiently intelligent perpetrators it may be challenging
to tell the difference.

47. ETIOLOGY
• The Swiss physician Mathey described kleptomania as early as the 19th century .
• There have been case reports of kleptomania being associated with head trauma,
frontal lobe lesions, cortical atrophy, dementia, and hypoglycemia.
• On diffusion tensor imaging, there is reduced fractional anisotropy in the inferior frontal
white matter in patients with kleptomania, implying that the disorder may be associated
with subtle white matter pathology.
• A study found that individuals with kleptomania had more first-degree relatives with
alcohol use disorders compared to controls. Serotonin and dopamine as well as the
opioid and glutamatergic neurotransmitter systems have been shown to play a role in
kleptomania.

48. CO-MORBID CONDITIONS
• Patients with kleptomania are said to have high lifetime comorbidity of major mood
disorders (usually, but not exclusively, depressive) and various anxiety disorders.
• Associated conditions also include other disorders such as pathologic gambling and
compulsive shopping, eating disorders (especially bulimia nervosa), personality
disorders, OCD, and substance use disorders, especially alcohol use disorder.
• Individuals with kleptomania are also reported to have higher rates of suicide.

49. COURSE AND PROGNOSIS
• The onset of the disorder generally is adolescence. In quiescent cases, loss or
disappointment may precipitate new bouts of the disorder.
• The course of the disorder waxes and wanes but tends to be chronic—the frequency of
stealing ranges from less than one to multiple episodes per month.
• Most patients with kleptomania steal from retail stores, but they may also take from
family members in their households.
• People with the disorder sometimes have bouts of being unable to resist the impulse
to steal, followed by free periods that last for weeks or months.
• The spontaneous recovery rate of kleptomania is unknown.
• Severe impairment and complications are usually secondary to being caught,
particularly to being arrested.

50. • consciously considered the possibility of facing the consequences of their acts. Often,
the disorder in no way impairs a person’s social or work functioning.
• The prognosis with treatment can be good, but few patients come for help of their
own accord.

51. RX
• Insight-oriented psychotherapy and psychoanalysis have been successful but depend on
patient’s motivations.
• Cognitive-behavioral therapy may be helpful.
• Specific behavior therapies - systematic desensitization, aversive conditioning, and a
combination of aversive conditioning and altered social contingencies, have been
reported successful, even when motivation was lacking.
• Specific therapies that are commonly implemented include parent management training (PMT),
multisystemic therapy (MST), and cognitive behavior therapy (CBT) with parent management.

52. • SSRIs, such as fluoxetine and fluvoxamine, appear to be effective in some patients with
kleptomania.
• Case reports indicated successful treatment with tricyclic drugs, trazodone, lithium,
valproate, topiramate, naltrexone, methylphenidate, and electroconvulsive therapy.
• Though limited by small sample size and open-label design, high-dose naltrexone was
reported to be effective in reducing the urge to steal in patients with kleptomania.

53. GAMBLING DISORDER
• Gambling disorder (GD) has been reclassified recently into the “Substance-Related and
Addictive Disorders” category of the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5), a landmark occurrence for a behavioral addiction.
• Characterized by recurrent, maladaptive gambling behavior that results in clinically
significant distress.
• Patients with GD are often characterized by cognitive distortions, such as illusions of control,
impulsive behavior, and dysfunctional personality traits.

54. MANAGEMENT
• Cognitive behavioral therapy (CBT) has become the most common psychological
intervention for treating GD and has been demonstrated to be effective in reducing
problem gambling behavior.
• SSRIs—paroxetine and fluvoxamine shown better results.

55. TRICHETELLOMANIA
• Trichotillomania is part of OCD and is thought to be largely related to anxiety disorders.
• In these cases the hair is pulled from anywhere on the body repeatedly, appearing as hair loss but
is caused by the action of the patient.
• Studies have shown thickening of the right inferior frontal gyrus, and others have shown reduced
cerebellar volumes.
• Positron emission tomography (PET), and single-photon emission computed tomography
(SPECT) studies have shown higher cerebral glucose metabolic rates in the cerebellum and right
parietal cortex and decreased perfusion of the temporal lobes.
• Habit reversal training is grounded in CBT techniques and it aims to identify cognitive
distortions and thought-action pairings and change them.
• positive effect of SSRI medications, but a more pronounced effect was seen with therapy. There
are more recent preliminary data that have shown some positive effects with olanzapine,
aripiprazole, and quetiapine.

56. MOBILE ADDICTION
• The problematic use of cell phones has been associated with personality variables, such as
extraversion, neuroticism, self-esteem, impulsivity, self-identity, and self-image.
• Impulsivity is another traditionally considered predictive dimension of cell-phone abuse,
and we have previously analyzed its role as a precursor or vulnerability factor for
behavioral addictions.

57. • Problematic and conscious use in dangerous situations or prohibited contexts with social and familial conflicts and
confrontations, as well as loss of interest in other activities A continuation of the behavior is observed despite the
negative effects or the personal malaise caused –
• Harm, repeated physical, mental, social, work, or familial interruptions, preferring the cell phone to personal
contact ; frequent and constant consultations in brief periods with insomnia and sleep disturbances
• Excessive use, urgency, abstinence, tolerance, dependence, difficulty controlling, craving, increasing use to achieve
satisfaction or relaxation or to counteract a dysphoric mood, the need to be connected, feelings of irritability or of
being lost if separated from the phone or of sending and viewing messages with feelings of unease when unable to
use it
• Anxiety and loneliness when unable to send a message or receive an immediate response ; stress and changes in
mood due to the need to respond immediately to messages

59. LAB INVESTIGATIONS
• Blood chemistry
• Liver and Thyroid function tests
• Fasting blood glucose
• Electrolytes
• Urinalysis (including drug toxicology), and syphilis serology may help rule
out other causes of aggression or impulsive behavior.
• Magnetic resonance imaging (MRI) may reveal changes in the prefrontal
cortex, which is associated with loss of impulse control.

60. ASSESSMENT
• Diagnosis requires a directed and systematic interview.
• There are several instruments for the screening of ICDs, such as
• Questionnaire for Impulse‐Compulsive Disorders in Parkinson's disease
(QUIP)
• Minnesota Impulsive Disorders Interview (MIDI)

61. TREATMENT PLANNING
• Individualized treatment plans should be developed to decrease impairments in
social and educational functioning.
• It is also prudent to identify and address comorbid psychiatric disorders,
including major depressive disorder, ADHD, anxiety disorder, and substance use
disorders.

62. PROGNOSIS
• Those with impulsive dispositions have poorer prognoses.
• Studies show that those with ICD have a high likelihood of experiencing future substance abuse,
depression, unemployment, and interpersonal relationship difficulties.
• Impulse control disorders tend to be chronic unremitting disenfranchising patterns of behavior. In
a more optimistic vein, intensive therapy, such as multi-systemic therapy (MST), has shown
reductions in rates of out of home placements and re-arrests.

63. COMPLICATIONS
• The most severe complications occur in those with CD. Males with CD will often have records
implicating vandalism, domestic abuse, and theft.
• Females with CD do not escape unscathed as they frequently have histories inclusive of deceit,
prostitution, and truancy.
• Complications of ODD can be severe if these individuals progress to CD and onto antisocial
personality disorder.

64. REFERENCES

65. THANK YOU