Internal Assessment
Psychopathology - II
PSYC627
Submitted by:
Ruhi Jain
A0403424425
M.A Clinical Psychology, Sem 2 (D)
1
Conduct Disorder and related Case Histories
A continuous pattern of behaviour that infringes upon the rights of others and significant social
norms is the hallmark of conduct disorder (CD), a complex and multidimensional mental health
illness that usually first appears in childhood or adolescence. These behaviours can include
major rule violations, property destruction, dishonesty or theft, and violence towards people and
animals. Children and teenagers with conduct disorders frequently show a marked disrespect for
authority figures and social norms, and their behaviour can have serious repercussions in the
classroom, in the community, and in the law.
According to epidemiological research, conduct disorder affects between 2% to 10% of children
and adolescents worldwide, with higher rates in males than in girls. However, prevalence varies
among cultures and demographics (American Psychiatric Association, 2013). The disorder
frequently coexists with other psychiatric conditions like Attention-Deficit/Hyperactivity
Disorder (ADHD), Oppositional Defiant Disorder (ODD), depression, and substance use
disorders. It is regarded as one of the most frequent causes of mental health referrals in children
and adolescents. It is noteworthy that up to 50% of kids with CD also fit the criteria for ADHD,
making diagnosis and treatment even more challenging (Hinshaw & Lee, 2003).
The aetiology of conduct disorder has been repeatedly shown to involve both genetic and
environmental components. A substantial hereditary component is suggested by twin and
adoption studies; estimates show that 40–50% of the variance in antisocial behaviour can be
attributed to genetic variables (Rhee & Waldman, 2002). Environmental factors that are also
highly linked include exposure to violence, parental psychopathology, inconsistent or severe
discipline, early abuse, and low socioeconomic position. Neurobiological research has revealed
anomalies in the hypothalamic-pituitary-adrenal (HPA) axis, amygdala, and prefrontal cortex,
indicating deficits in decision-making, emotional control, and stress response systems (Blair,
2013).
Crucially, the DSM-5 adds a specifier for conduct disorder: "with limited prosocial emotions,"
which encompasses callous-unemotional characteristics including guilt, shallow affect, and lack
of empathy. This specifier is linked to a worse prognosis, earlier onset, and more severe
symptoms. If early assistance is not given, adolescents who have these characteristics are also
far more likely to acquire antisocial personality disorder as adults.
2
According to developmental psychopathology, conduct disorder is a trajectory-based condition in
which, if untreated, early disruptive behaviour issues can eventually grow into more serious
conduct issues. By distinguishing between "life-course persistent" and "adolescence-limited"
subtypes of antisocial behaviour, longitudinal studies like the Dunedin Multidisciplinary Health
and Development Study (Moffitt et al., 1996) have provided a more nuanced picture of the path
of antisocial behaviour.
A multi-modal, multi-systemic approach is needed to manage conduct disorder, which may
involve family interventions, school-based tactics, individual psychotherapy, and medication as
needed. Since untreated CD is linked to serious long-term outcomes such as school dropout,
criminal behaviour, substance abuse, and adult psychiatric illnesses, early detection and
intervention are essential.
In light of its high prevalence, significant burden, and far-reaching implications, Conduct
Disorder remains a priority area for child and adolescent mental health research. Future
directions should focus on improving early detection methods, identifying biomarkers, enhancing
access to evidence-based interventions, and addressing systemic inequalities that contribute to its
development and maintenance.
Following case histories present insight into the disorder in a clearer manner:
3
Case History 1: Rahul
1. Identifying Information:
Name: Rahul S.
Age: 12 years
Gender: Male
Education: Class 7th, Government School, Delhi
Informant: Mother (Reliable)
2. Presenting Complaints:
● Aggressive behavior towards peers – 2 years
● Repeated lying and stealing – 1.5 years
● Destruction of property – 1 year
● Cruelty towards animals – 6 months
● Lack of remorse or guilt – observed throughout
3. History of Present Illness:
Rahul was brought to the child guidance clinic by his mother due to increasing aggressive
behavior at home and school. Over the past two years, he has displayed hostility towards
classmates, often engaging in fights and bullying. His teachers report that he steals lunch boxes,
pens, and money. At home, he has broken window panes, slashed his sister’s books, and was
once caught burning paper in the bathroom. Recently, neighbors reported him throwing stones at
stray dogs. When confronted, Rahul laughs or blames others.
4
4. Past Psychiatric History:
No formal psychiatric diagnosis in the past, though school counselors had recommended therapy
a year ago, which the family did not pursue.
5. Past Medical History:
No significant medical illness reported. Immunizations up to date.
6. Family History:
● Father: Alcoholic, emotionally distant, often absent
● Mother: History of depression, homemaker
● Sister: 8 years old, shy, no behavioral complaints
● No family history of psychiatric illness reported
7. Personal History:
a. Birth and Developmental History:
Full-term normal delivery, birth weight 3.2 kg. Developmental milestones within normal limits.
b. Childhood History:
Described as hyperactive and stubborn. Frequent tantrums, poor response to discipline.
c. Educational History:
Average academic performance till Class 4. Post that, increasing behavioral issues. Multiple
complaints from teachers. Has changed 2 schools already.
d. Peer Relationships:
Poor. Often dominates or bullies peers. No close friendships. Preferred by younger children due
to manipulative behavior.
5
e. Substance Use History:
None reported.
8. Premorbid Personality:
Described as impulsive, moody, demanding, and emotionally detached.
9. Mental Status Examination (MSE):
● Appearance: Casual, neat, good hygiene
● Behavior: Restless, mildly defiant, poor eye contact
● Speech: Coherent, appropriate volume and pace
● Mood: Irritable
● Affect: Blunted
● Thought Content: No delusions or hallucinations
● Cognition: Alert, oriented, average attention span
● Insight: Absent
● Judgment: Poor
10. Physical Examination: No significant findings.
11. Provisional Diagnosis (DSM-5): Conduct Disorder, Childhood-Onset Type, Moderate
Severity
12. Formulation: Rahul’s symptoms are consistent with Conduct Disorder. Early family
dysfunction, particularly paternal neglect and maternal depression, likely contributed to poor
6
emotional regulation and attachment issues. School environment and peer rejection may have
exacerbated externalizing behaviors.
13. Management Plan:
● Cognitive Behavioral Therapy (CBT) for anger management and problem-solving
● Parent Management Training to promote consistent discipline and support
● School intervention plan for behavior modification
● Animal-assisted therapy to promote empathy and emotional bonding
● Psychoeducation for family regarding conduct disorder
14. Prognosis: Guarded, given early onset, lack of remorse, and family dysfunction. However,
early intervention and consistent therapy could improve outcomes.
7
Case History 2: Aisha
1. Identifying Information:
Name: Aisha K.
Age: 15 years
Gender: Female
Education: Dropped out in Class 9
Informant: Mother (Partially reliable)
2. Presenting Complaints:
● Frequent truancy and staying out at night – 1.5 years
● Stealing money and valuables from home – 1 year
● Involvement in fights and group violence – 10 months
● Alcohol and drug use – 6 months
3. History of Present Illness:
Aisha was referred by the juvenile justice board after being involved in a shoplifting and
physical assault case. She began skipping school around age 13 and was eventually expelled due
to repeated behavioral violations. At home, she shows little respect for her mother, often
shouting and using foul language. She has admitted to drinking alcohol and using cannabis with
friends. She is part of a group of older adolescents known for illegal activities in the area.
Despite multiple warnings, she has not shown remorse or change in behavior.
4. Past Psychiatric History:
No formal history. A teacher once suggested therapy for aggressive behavior, but the family was
unable to follow through due to financial issues.
5. Past Medical History: No history of major medical illness. Regular menstrual cycle.
8
6. Family History:
● Single-parent home; father left when she was 5
● Mother works two jobs, unable to supervise Aisha
● Elder brother (18) has been arrested for theft twice
● No formal psychiatric history in family
7. Personal History:
a. Birth and Developmental History:
Full-term delivery, normal birth weight. Developmental milestones achieved on time.
b. Childhood History:
Described as stubborn and oppositional. Had difficulty forming attachments after father left.
c. Educational History:
Initially regular attendance till Class 6. Then started failing exams and being suspended.
Dropped out at Class 9.
d. Peer Relationships: Initially had few friends. Later associated with delinquent peer groups.
Tends to dominate or manipulate others.
e. Sexual History: Admits to multiple sexual relationships. Engages in unprotected sex,
occasionally in exchange for money or gifts.
f. Substance Use History: Alcohol and cannabis use for 6 months. Claims occasional tobacco
use.
8. Premorbid Personality: Bold, impulsive, thrill-seeking, lacked empathy, emotionally
detached.
9. Mental Status Examination (MSE):
● Appearance: Casual, slightly provocative clothing, adequate hygiene
9
● Behavior: Overconfident, occasionally hostile
● Speech: Loud, rapid, mildly aggressive tone
● Mood: Irritable
● Affect: Blunted
● Thought Content: No delusions or hallucinations
● Cognition: Alert, oriented, superficial concentration
● Insight: Absent
● Judgment: Severely impaired
10. Physical Examination: Needle marks not found. No signs of malnourishment. Normal
vitals.
11. Provisional Diagnosis (DSM-5): Conduct Disorder, Adolescent-Onset Type, Severe
12. Formulation: Aisha's condition likely stems from early abandonment, unstable family
structure, and exposure to criminal behavior in both family and peers. Her emotional detachment,
lack of remorse, and poor school engagement have contributed to severe antisocial behaviors.
13. Management Plan:
● Multisystemic Therapy (MST): Addressing family, school, and peer systems
● Trauma-informed therapy to explore possible past abuse
● Substance use counseling
10
● Vocational training to improve future prospects
● Legal supervision and regular monitoring
14. Prognosis: Poor to guarded, given the severity of symptoms, substance abuse, and lack of
support system. Early intervention and structured programs may improve behavior.
11
Case History 3: Raghav
1. Identifying Information:
Name: Raghav S.
Age: 17 years
Gender: Male
Education: Dropped out after Class 10
Informant: Juvenile Justice Board records, maternal uncle (partially reliable)
2. Presenting Complaints:
● Persistent aggressive behavior, cruelty towards animals – 3 years
● Frequent law-breaking behavior, including robbery and vandalism – 2 years
● Manipulative, shows no remorse – 2+ years
● Suspended and expelled from school for violent conduct – 2 years
3. History of Present Illness:
Raghav was referred for psychological assessment after repeated run-ins with the law, including
a recent case of group assault and robbery. He has a history of severe physical aggression, such
as stabbing a schoolmate with a pencil and pushing another off a bicycle causing head injury. He
has set small fires in his neighborhood and killed stray dogs “for fun.” Raghav does not seem to
experience guilt or anxiety, and has admitted to lying frequently to manipulate both peers and
adults. He does not maintain friendships, sees others as weak or stupid, and enjoys watching
others suffer. He often intimidates younger children and is feared by local residents.
4. Past Psychiatric History: None formally diagnosed, but multiple behavioral complaints
recorded in school and juvenile centers.
5. Past Medical History: Unremarkable. No history of neurological illness or major physical
ailments.
12
6. Family History:
● Father: Alcohol-dependent, physically abusive to family, died in an accident 4 years ago
● Mother: Left home when Raghav was 10; whereabouts unknown
● Raised by maternal uncle, who reports “no emotional connection”
● No psychiatric illnesses officially diagnosed in family, but suggestive signs in father
7. Personal History:
a. Birth and Developmental History:
Home birth; no documented birth records. Recurrent childhood infections. Developmental
milestones not closely tracked but reportedly within normal range.
b. Childhood History:
Very withdrawn as a child. Began lying and stealing as early as age 7. Bullied others in school
from Class 3 onwards. Enjoyed watching violent media.
c. Educational History:
Failed in Class 9, repeated, but then dropped out due to expulsion after stabbing a peer. Teachers
noted he was intelligent but disinterested in academics.
d. Peer Relationships:
Associated mostly with older adolescents involved in petty crime. Uses others for gain; no
genuine friendships.
e. Sexual History:
Multiple unprotected sexual encounters. History of coercive behavior toward girls in his peer
group.
f. Substance Use History:
Alcohol use from age 14, tobacco from age 13, occasional sniffing of whitener.
13
8. Premorbid Personality: Cold, manipulative, low empathy, lacked close bonds. Calculated
in behavior. No expression of guilt or shame.
9. Mental Status Examination (MSE):
● Appearance: Tall, lean, unkempt; indifferent body language
● Behavior: Calm, confident, slightly intimidating
● Speech: Controlled, sarcastic at times
● Mood: Neutral to dismissive
● Affect: Flat
● Thought Content: No psychosis; grandiosity noted
● Cognition: Intact memory, above-average intelligence, high reasoning skills
● Insight: Absent
● Judgment: Impaired – unable to differentiate right from wrong in moral context
10. Physical Examination:
No signs of physical illness. Several tattoos and burn marks on arms (some self-inflicted, others
as part of group rituals).
11. Provisional Diagnosis (DSM-5):
● Conduct Disorder, Adolescent-Onset Type, Severe
● With Limited Prosocial Emotions (Specifier: Callous-Unemotional Traits)
12. Formulation: Raghav presents with early signs of emotional detachment, high impulsivity,
and antisocial behavior. A severely disrupted attachment history, abusive early environment, and
a lack of consistent caregiving contributed to the development of callous-unemotional traits and
a chronic pattern of conduct disorder. His indifference to others' suffering and absence of guilt
are highly concerning prognostic features.
14
13. Management Plan:
● Intensive Individual Therapy: Motivational interviewing, anger management, and
empathy training
● Multisystemic Therapy (MST): Engage remaining family and community resources
● Cognitive Behavioral Therapy (CBT) focused on moral reasoning and social
problem-solving
● Referral to Juvenile Rehabilitation Services with structured activities and legal
supervision
● Psychiatric Evaluation: Consider mood stabilizers (e.g., risperidone for aggression)
after full risk assessment
14. Prognosis: Guarded to poor, especially due to limited prosocial emotions, high recidivism
risk, and lack of support system. Requires long-term, structured intervention and supervision.
15
Case History 4: Arjun
1. Identifying Information:
Name: Arjun P.
Age: 9 years
Gender: Male
Education: Class 4, Private School
Informant: Both parents (Reliable)
2. Presenting Complaints:
● Difficulty following rules at home and school – 3 years
● Hitting classmates and throwing objects – 2 years
● Disobedient and argumentative with adults – 2.5 years
● Attention issues, hyperactivity – 3 years
3. History of Present Illness:
Arjun was brought in due to persistent behavioral issues in class and at home. He frequently
interrupts the teacher, leaves his seat without permission, and talks excessively. He has hit peers
with sticks and once locked another child in the bathroom. At home, he refuses to follow any
instructions, throws tantrums, and has broken household items including the television. He was
once caught trying to light a match under the bed. His parents report that he seems unconcerned
about consequences and is indifferent to punishment.
4. Past Psychiatric History: Diagnosed with ADHD at age 7. Was started on behavioral
therapy, which was later discontinued due to lack of follow-up.
5. Past Medical History: No significant medical conditions. History of frequent colds and
allergies in early childhood.
16
6. Family History:
● Father: IT professional, described as strict and irritable
● Mother: Homemaker, mild anxiety symptoms
● No history of psychiatric illness or neurological disorder
● Arjun is the only child
7. Personal History:
a. Birth and Developmental History: Delivered via C-section at 38 weeks, birth weight 2.7 kg.
Cried immediately after birth. Developmental milestones were mildly delayed (walked at 16
months, spoke at 2 years).
b. Childhood History: Restless, active child. Temper tantrums started at age 3. Avoided eye
contact during early years.
c. Educational History: Enrolled in school at age 4. Initially okay, but problems started by Class
1. Multiple complaints from teachers, often removed from class.
d. Peer Relationships: Very few friends. Often teased or avoided by classmates. Parents report
he talks only to younger children or plays alone.
e. Substance Use History: Not applicable
8. Premorbid Personality: Hyperactive, noncompliant, difficulty sitting still or engaging in
quiet activities. Easily frustrated.
9. Mental Status Examination (MSE):
● Appearance: Neatly dressed, active and fidgety
● Behavior: Distractible, impulsive, frequently interrupts
● Speech: Loud, fast-paced
17
● Mood: Irritable
● Affect: Labile
● Thought Content: No hallucinations or delusions
● Cognition: Alert, disorganized thought process, poor attention span
● Insight: Absent
● Judgment: Poor
10. Physical Examination: Normal height and weight for age. No neurological deficits
observed.
11. Provisional Diagnosis (DSM-5):
● Conduct Disorder, Childhood-Onset Type, Mild
● Comorbid Attention-Deficit/Hyperactivity Disorder (Combined Presentation)
12. Formulation: Arjun exhibits both externalizing behaviors typical of conduct disorder and
symptoms of ADHD. A lack of consistent discipline, early signs of poor frustration tolerance,
and limited peer relationships have worsened his behavior. ADHD has further impaired his
ability to regulate impulses.
13. Management Plan:
● Parent Management Training (PMT) for consistent behavioral reinforcement
● Child Behavior Therapy focusing on emotion regulation and social skills
● School-based behavioral intervention plan
● Psychoeducation for teachers and caregivers
18
● Medication review for ADHD (methylphenidate trial suggested)
14. Prognosis: Fair, with early diagnosis and structured interventions. Prognosis improves with
consistent therapy and parental involvement.
