Galvin, Matthew R.

Stilwell, Barbara M.

IUPUIScholarWorks

Reconceptualizing Disorders of ConductBarbara M. Stilwell, M.D. and Matthew R. Galvin, M.D.The Moral Realm of Human Experience• Deals with good and bad, right and wrong• Incorporates all domains of development• Attachment• Emotion• Cognition: Perception, Memory, Language, Reasoning• Behavior• Results in personal conscience• Collectively results in public conscience (ethics)Personal Conscience• Maintains the moral realm in consciousness• Provides a sense of oughtness• Is an integration of many developmental pathways• Is subject to malfunctioning due to• delayed, deficient, or deviant development• psychopathological interference• human fallibilityFive Domains of Conscience • Anchor Domain: Conceptualization• Interlocking Supporting Domains – Moralization of Attachment– Moral-Emotional Responsiveness– Moral Valuation– Moral VolitionMoralizing Moments Form the Conscience • In a relationship of importance• An event of moral importance occurs.• Emotions rise and fall according to how the event is resolved.• Cognitive processing produces a value-laden rule.• The rule affects current and future behavior.• The experience is stored in memory for future use or modification.Five Hierarchical Stages of Conscience in Childhood and Adolescence• External Conscience Stage (6 and before)• Brain/Heart Stage (7-11)• Personified Stage (12-13)• Confused Stage (14-15)• Integrating Stage (16-17+)Looking for Domains of Conscience Within DSM-IV DiagnosesConduct Disorder• Violation of "basic rights of others or major age-appropriate societal norms or rules"– Moral valuation and moral volition domains• Aggression to people and animals; destruction of property; deceitfulness or theft, serious violation of rules– Moral volition domainOppositional Defiant Disorder (1)• "pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures" – Moral attachment; moral volition domain • "Touchy...annoyed... Angry...resentful"– Moral-emotional responsiveness domain• "Blames, spiteful, vindictive"– Moral valuation and moral volition domainsOppositional Defiant Disorder (2)• …"Loses temper;...argues with adults; ….Defies or refuses to comply with adults' requests or rules"– Moral attachment, moral valuation, and moral volition domainsImpulse Control Disorders Not Elsewhere Classified• "…failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others"– Moral attachment, valuation, and volition domains• Intermittent Explosive Disorder; Kleptomania; Pyromania; Pathological Gambling; Trichotillomania; NOSAntisocial Personality Disorder(1 of 2)• "disregard for and violation of the rights of others occurring since age 15…"– Moral valuation and moral volition domains• "Failure to conform to social norms…deceitfulness"– Moral valuation and moral volition domainsAntisocial Personality Disorder(2 of 2)• "Impulsivity;…failure to plan ahead; irritability and aggressiveness; reckless disregard for safety of self or others; consistent irresponsibility"– Moral-emotional responsiveness, moral valuation, and moral volition domains• Lack of remorse– Moral-emotional responsiveness domainDSM Disorders That Have an Inherently Moral Focus Would Benefit from being Reclassified as a Five-Domain Disorder of ConscienceWhy?• We need domain-specific operationalized criteria in order to study:– Domain-specific biological correlates– Domain-specific treatmentsDefining Domains of ConscienceConscience Conceptualization Domain• The Anchor Domain• Verbal and Pictorial Description• Integrates Supporting Domains into an "Executive Moral Command Center"• Five Stages in Normal Development Between 5 and 17Moral Attachment Domain• Humans are bioevolutionarily programmed for attachment.• In addition, parents are socially programmed for bonding.• Security-empathy-oughtness mental representation• Forms a moral interpersonal connection• self with others• self with conscience Moral-Emotional Responsiveness Domain• Moral-emotional barometer• Set point: Am good; Feel good; Ready to do good• Moralized anxiety• Moralized mood • Psychophysiological Awareness• Reparation and Healing Moral Valuation Domain• Valuational Triangle: authority-derived, self-derived, peer-derived rules for living • Moral Justification• Moral reasoning• Psychological defenses• Temperamental characteristics• Psychophysiological reactions (stress, fatigue) Moral Volition Domain• Autonomy and Will• Developmental Self-Identified Tasks of Oughtness• Restraint• Mastery/sufficiency• Virtuous striving• Idealization• Individual Responsibility for Choice• Self-EvaluationGradients in Conscience Dysfunction• Excesses (e.g. in OCD)• Delays • Deficiencies• Overt Deviancies• Covert Deviancies• --------• Disruption (e.g. in PTSD or depression) Disorder of Conscience Functioning • A.  A repetitive and persistent pattern of delay, deficiency, or deviancy in the moralization of attachment, emotional responsiveness, valuation, volition, and conceptualization of personal conscience manifested by one or more criteria in each of the following domains for at least the last six monthsMoralization of Attachment Relationships (Slide 1)• 1.  Acknowledges or demonstrates desire for positive relationship with attachment figures, but repeatedly and persistently fails to internalize their rearing demands and prohibitions as personal moral imperativesMoralization of Attachment Relationships (Slide 2)• 2.  Acknowledges or demonstrates no desire for relationship with attachment figures as well as blatantly resisting their rearing demands and prohibitions• 3.  Acknowledges a paucity of childhood memories affirming basic goodness or having done good deedsMoral-Emotional Responsiveness (Slide 1)• 1.  Acknowledges or demonstrates a variety of emotions, but fails to regulate them around the pursuit of goodness/rightfulness or the restraint of badness/wrongfulness• 2.  Acknowledges or demonstrates limited emotional or physiological arousal to demands and prohibitions Moral-Emotional Responsiveness (Slide 2)• Acknowledges or demonstrates marked difficulty empathizing with the emotional responsiveness of othersMoral Valuation (Slide 1)• 1.  Acknowledges or demonstrates repeated and persistent devaluation of moral imperatives of authority figures or institutions– a.  With defensive justification– b.  With callous disrespectMoral Valuation (Slide 2)• Acknowledges or demonstrates repeated and persistent devaluation of moral imperatives governing peer relationships or peer communities– a.  With defensive justification– b.  With callous disrespectMoral Valuation (Slide 3)• 3.  Acknowledges or demonstrates repeated and persistent devaluation of moral obligations to the self– a.  With defensive justification– b.  With callous disrespectMoral Volition (Slide 1)• 1.  Acknowledges or demonstrates deceptive behavior destructive of– a.  Relationship with family members (including pets and property)– b.  Relationship with authority figures and institutions– c.  Relationship with peers and the egalitarian community– d.  Relationship with selfMoral Volition (Slide 2)• 2.  Acknowledges or demonstrates overtly aggressive behavior destructive of– a.  Relationship with family members (including pets and property)– b.  Relationship with authority figures and institutions– c.  Relationship with peers and the egalitarian community– d.  Relationship with selfPersonal Conceptualization of Conscience• 1.  Demonstrates developmental delay in the organization of a personal conscience• 2.  Demonstrates value deficiency in the organization of a personal conscience• 3.  Demonstrates value deviancy in the organization of a personal conscience• 4.  Demonstrates disruption to previously organized personal conscienceB.  The disturbance in the moralization of attachment, emotional responsiveness, valuation, volition, and conceptualization of conscience causes clinically significant impairment in individual well-being or interpersonal functioning within family, school, and community settings.C.  If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder (or criteria for an adult Disorder of Conscience yet to be defined).Specify type based on age of onset:• Childhood-Onset Type: onset of at least one criterion from each domain prior to age 10• Adolescent-Onset Type: onset of at least one criterion from each domain prior to age 10Specify severity (Mild)• Delays in conscience development are prominent (i.e., could be considered normal in a younger child).  Demonstrates mild resistance to self-examination or modification in one or more of the five domains of conscience (i.e., improving relationships with attachment figures; attaching emotional significance to issues of good and bad; right or wrong; developing and processing personal moral rules; controlling behavior; and defining a personal conscience).Specify severity (Moderate)• In addition to delayed conscience development, deficiencies in conscience functioning are prominent (e.g., inadequate development of personal moral rules).  Demonstrates moderate resistance to self-examination or modification in one or more of the five domains of conscience.Specify severity (Severe)• In addition to delays and deficiencies, deviancies in conscience functioning are the prominent feature (e.g., intent to be devious, aggressively harmful, or both).  Demonstrates severe resistance to self-examination or modification in any of the domains of conscience.D.  Relationship to Comorbidity• A Disorder of Conscience Functioning may be an independent diagnosis or it may be secondary to psychopathological interference from other diagnoses (e.g. PTSD, mood disorders, ADHD, substance abuse, psychotic disorders).  Treatment of comorbid psychopathology may free the individual for further conscience development and improved functioning.E.  The Disorder of Conscience Functioning is not better defined by another disorder.Disorder of Conscience Functioning Not Otherwise Specified• This category is for a disorder of conscience functioning in which one or more of the five domains is unimpaired.Conduct Disorder Research: Relevance to the Rationale for a  Disorder of Conscience FunctioningSocial Learning ModelSnyder, Reid, Patterson• Social behavior, anti- or pro, results from an interaction of• Person (including individual traits)• Environmental influences• Cumulative moral meaning in personal conscience• Moralizing moments can be antisocializing • Coercive and manipulative• Aversive, inconsistent, unsupportive environment• Moral meaning skewed in direction of self entitlement "Persistent and serious antisocial behavior…• Children’s failure to…– self-regulate emotions– deploy attention– problem solve– engage in autonomous rule following– relate effectively to others"• All conscience domains represented in this quoteLife Course Persistent; Adolescent-Limited ModelTerrie E Moffitt• Age/stage gradient in normal conscience development• Proposed gradient in disorders of conscience – delay– deficiency– overtly or covertly deviant– disruptedDevelopmental Propensity ModelLahey and Waldman• Temperamental Propensity to CD• High Negative Emotionality• High Daring• Low Prosociality• Rearing can modify the effects of temperament• Propensity/restraint learning stored in conscienceCommunity Influence on Pathways in CriminalityWikstrom and Sampson• Individual propensity toward crime (morality and self-control) interacts with• Behavior settings that provide temptation, provocation, and weak deterrence to produce faulty exercise of• Agency, perception of options, and choice Antisocial Behavior in First Years of LifeKeenan and Shaw• Emotional dysregulation + Inadequate caretaker environment• Pathways of vulnerability• Irritable infant in overstimulating environment• Underaroused infant in overstimulating environmentSocialization Failure; Chronic Physical AggressionRichard E. Tremblay• Physical aggression• biologically programmed• peaks in early childhood• Socialization process• learning to regulate one's pleasure seeking to that of others• unlearning physical aggression Executive Functions and Intelligence (1)Nigg and Huang-Pollock• Intelligence: ability to adapt, learn, and engage• CD: lower IQ scores; deficits in verbal learning and verbal reasoning• Executive Functions: • set shifting• interference control• inhibition• planning; working memoryExecutive Functions and Intelligence (2)• Neuroimaging• Parallel loops connnecting– Prefrontal cortex– Basal ganglia• Three interacting processes in conduct problems• Motivational (affective) response• Inhibitory and attentional control• Verbal developmentSocial Information ProcessingKenneth A Dodge• Patterns of SIP are personality-like traits• SIP predicts aggressive behavior• Attributions of hostile intent• Measurements• Selective attention• Intent attributions• Response generation• Response evaluationPrefrontal Deficits (1)Ishikawa and Raine• Dorsolateral prefrontal cortex• Working memory• Executive functions• Orbitofrontal cortex regulates• autonomic reactivity• social and self-awareness• regulation of affectPrefrontal Deficits (2)• Ventromedial prefrontal cortex implicated • risk-related• emotion based decision making• deficits may be specific to sociopaths • Dorsal anterior cigulate• monitoring• decision formation• Poor fear conditioning: poor conscience development (Raine, 1993)Prefrontal Deficits (3)• Damasio's somatic markers• Alert individuals to threatening situations• Allows homeostasis while• Guiding behavior toward advantageous decision making• Amygdala• Affective regulation and memory Summary• Reconceptualizing Disorders of Conduct into a Disorder of Conscience Functioning is not an exercise in creativity.     • It recognizes the moral realm of human development and• Reorganizes the tributaries of that stream of development utilizing known clinical and biological research.  Return to Conscience Works home page

Reconceptualizing Disorders of Conduct

https://scholarworks.iupui.edu/bitstream/1805/16409/4/ReconceptualizingDisordersofConduct.pdf

Reconceptualizing Disorders of Conduct

Abstract

Similar works

Full text

Available Versions

IUPUIScholarWorks