Psychiatric disorders are diagnosed by determining the presence of specific symptoms, mostly without regards for what caused the symptoms. That is, if you have a specific number of symptoms and meet some additional criteria, then by definition, you have the disorder. For the most part, the rest of medicine doesn’t work this way. If you have a strong headache a neurologist won’t simply tell you that you have a brain tumor. The neurologist is interested in examining the origins of the headache (here I purposely avoided using of the word “cause” ) which would then lead to a more accurate diagnosis. In psychiatry we do this significantly less often because psychiatry exclusively uses a descriptive symptom-base approach to defining psychiatric disorders. Although in most cases this approach leads to useful and valid classifications of psychiatric disorders, there is one domain I believe the system fails miserably: attention and behavioral disorders. I will leave the discussion on attention disorders for another day, but today I want to write about behavioral disorders.
There is a psychiatric disorder called Conduct Disorder. This disorder refers to a pervasive pattern of behaviors in which “the basic rights of others or major age-appropriate societal norms or rules are violated“. The symptoms of this disorder may involve bullying, fighting, using weapons to harm others, being cruel to people or animals, stealing, destroying property, fire setting, etc. Under this definition, many if not most kids in the juvenile justice system (especially repeat offenders) would meet the criteria for this psychiatric disorder. Thus, by definition, you could argue that having chronic behavioral problems and engaging in criminal behavior is considered a psychiatric disorder. My problem with this position is that it assumes that kids who engage in these behaviors have true neurocognitive impairments that result in such behaviors. In many cases this is true, but not in all cases. I should note here that I take a commonly, but not always, accepted view of psychiatric disorders. Regardless of the “cause,” psychiatric disorders involve impairments in neurocognitive processes that impact a persons emotions, cognition, or behaviors. So, do kids diagnosed with Conduct Disorder truly have a psychiatric disorder? That is, do they truly have impairments in neurocognitive processes that impact their behaviors? Some do, but not all.
What is ironic about this issue is that conduct disorder is recognized as a psychiatric disorder but “psychopathy” is not (at least psychopathy is not included in the Diagnostic and Statistical Manual of Mental Disorder). I say ironic because there is mounting evidence that psychopathy involves marked impairments in neurocognitive processes that affect behavior. What is psychopathy? It is a personality construct that refers to extremes in specific personality traits. Notably, people with high levels of psychopathy (there is debate as to whether psychopathy is a categorical – your have it or your don’t – or a continuous construct) have very high callous-unemotional traits, which refer to a persistent lack of empathy, guilt, emotional depth, and concern for others. Interestingly, only a subset of kids diagnosed with Conduct Disorder also have high levels of psychopathy. Those are, in my view, the kids with a true psychiatric disorder because among these kids, it is a true impairment in neurocognitive functioning –an inability to experience empathy or guilt – that contribute to their behavioral problems.
This week I read a study that provided more evidence of cognitive anomalies among kids with psychopathic traits. In the most recent issue of the Journal of Child Psychology and Psychiatry a team from Australia and the London published a study examining eye contact in 92 male children diagnosed with conduct disorder or oppositional defiant disorder. The children were also assessed on a measure of callous-unemotional traits and were observed interacting with their parents in an unstructured (free play) and structured (discussion of emotional topic) activity. The kids’ behavior during these task was coded for frequency of reciprocal eye contact with their parents. The researchers were interested in examining whether those kids with high levels of callous-unemotional traits had different patterns of eye contact with their parents than their peers.
As you can see above, kids with high levels of callus-unemotional traits (dark bars) engaged in significantly less eye contact with their parents than kids with low levels of callus-unemotional traits. What is significant about this finding is that all of the participants had a diagnosis of a behavioral disorder. Yet, only a subset of these kids scored high on a psychopathy construct and this same subset displayed impairment in normative eye contact processes with their parents. Why is eye contact relevant? The authors stated:
First, impairments in the natural tendency to attend to affective stimuli, long associated with psychopathic traits, occur early in life in naturalistic settings, in this case, as impairments in making eye contact during free and emotionfocused discussions with attachment figures. Second, the results are consistent with Blair’s idea that psychopathy is in part due to a failure of the violence inhibition mechanism such that a failure to notice distress cues disrupts the potential of such cues to inhibit aggressive behaviour and more generally, to be internalised as aversive stimuli that effectively promote the development of moral conscience (Blair, 1995). Third, the impairment in eye contact is likely to be a mechanism that helps explain why children with high CU traits are less responsive to quality of parenting (Hawes & Dadds, 2005; Oxford, Cavell, & Hughes, 2003; Viding et al., 2005; Wootton et al., 1997), and fail to develop normal levels of affective empathy (Blair, 2008; Dadds et al., 2009).
In conclusion, this study provided more evidence that a subset of kids diagnosed with conduct disorders display features of psychopathy and impairment in social-cognitive processes (eye contact) that may contribute to their behavioral difficulties.
The reference: Dadds, M., Jambrak, J., Pasalich, D., Hawes, D., & Brennan, J. (2010). Impaired attention to the eyes of attachment figures and the developmental origins of psychopathy Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2010.02323.x
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