DSM-III

In DSM-III, this disorder is called Oppositional Disorder

Diagnostic Criteria

A. Onset after 3 years of age and before age 18.

B. A pattern, for at least six months, of disobedient, negativistic, and provocative opposition to authority figures, as manifested by at least two of the following symptoms:

  1. violations of minor rules
  2. temper tantrums
  3. argumentativeness
  4. provocative behavior
  5. stubbornness

C. No violation of the basic rights of others or of major age-appropriate societal norms or rules (as in Conduct Disorder); and the disturbance is not due to another mental disorder, such as Schizophrenia or a Pervasive Developmental Disorder.

D. If 18 or older, does not meet the criteria for Passive-Aggressive Personality Disorder.

Differential Diagnosis

Normal oppositional behavior

Oppositional behavior in 18-to-36-month-old children is part of a normal developmental phase. The diagnosis of Oppositional Disorder should be considered only if severe oppositional behavior persists beyond this period.

Conduct Disorder

In Conduct Disorder there is violation of either the basic rights of others or major age-appropriate societal norms and rules, whereas in Oppositional Disorder the disturbance is never so severe and therefore does not extend to persistent lying, violation of major rules (e.g., truancy), theft, physical aggression, or vandalism. In some instances what first appears to be Oppositional Disorder may later turn out to be an early manifestation of Conduct Disorder.

Schizophrenia and Pervasive Developmental Disorders

In Schizophrenia and Pervasive Developmental Disorders there may be persistent oppositional behavior. However, if the oppositional behavior is due to these disorders, the diagnosis of Oppositional Disorder is not made.

Attention Deficit Disorder, Mental Retardation, and Organic Mental Disorders

Some cases of Attention Deficit Disorder, Mental Retardation, or chronic Organic Mental Disorders may also meet the criteria for this disorder, in which case both diagnoses should be made.

DSM-IV

Diagnostic Criteria

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

  1. often loses temper
  2. often argues with adults
  3. often actively defies or refuses to comply with adults' requests or rules
  4. often deliberately annoys people
  5. often blames others for his or her mistakes or misbehaviors
  6. is often touchy or easily annoyed by others
  7. is often angry and resentful
  8. is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Differential Diagnosis

Conduct Disorder

The disruptive behaviors of individuals with Oppositional Defiant Disorder are of a less severe nature than those of individuals with Conduct Disorder and typically do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. Because all of the features of Oppositional Defiant Disorder are usually present in Conduct Disorder, Oppositional Defiant Disorder is not diagnosed if the criteria are met for Conduct Disorder.

Mood Disorders and Psychotic Disorders

Oppositional behavior is a common associated feature of Mood Disorders and Psychotic Disorders presenting in children and adolescents and should not be diagnosed separately if the symptoms occur exclusively during the course of a Mood or Psychotic Disorder.

Attention-Deficit/Hyperactivity Disorder

Oppositional behaviors must also be distinguished from the disruptive behavior resulting from inattention and impulsivity in Attention-Deficit/Hyperactivity Disorder. When the two disorders co-occur, both diagnoses should be made.

Mental Retardation

In individuals with Mental Retardation, a diagnosis of Oppositional Defiant Disorder is given only if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable age, gender, and severity of Mental Retardation.

Impaired language comprehension

Oppositional Defiant Disorder must also be distinguished from a failure to follow directions that is the result of impaired language comprehension (e.g., hearing loss, Mixed Receptive-Expressive Language Disorder).

Certain developmental stages

Oppositional behavior is a typical feature of certain developmental stages (e.g., early childhood and adolescence). A diagnosis of Oppositional Defiant Disorder should be considered only if the behaviors occur more frequently and have more serious consequences than is typically observed in other individuals of comparable developmental stage and lead to significant impairment in social, academic, or occupational functioning. New onset of oppositional behaviors in adolescence may be due to the process of normal individuation.

DSM-5

Diagnostic Criteria

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidence by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

  • Angry/Irritable Mood
  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
    • Argumentative/Defiant Behavior
  4. Often argues with authority figures or, for children and adolescents, with adults.
  5. Often actively defies or refuses 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.
    • Vindictiveness
  8. Has been spiteful or vindictive at least twice within the past 6 months.

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise notes (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual's developmental level, gender, and culture.

B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Specify current severity:

  • Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
  • Moderate: Some symptoms are present in at least two settings.
  • Severe: Some symptoms are present in three or more settings.

Specifiers

It is not uncommon for individuals with oppositional defiant disorder to show symptoms only at home and only with family members. However, the pervasiveness of the symptoms is an indicatory of the severity of the disorder.

Differential Diagnosis

Conduct disorder

Conduct disorder and oppositional defiant disorder are both related to conduct problems that bring the individual in conflict with adults and other authority figures (e.g., teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of conduct disorder and do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder.

Attention-deficit/hyperactivity disorder

ADHD is often comorbid with oppositional defiant disorder. To make the additional diagnosis of oppositional defiant disorder, it is important to determine that the individual's failure to conform to requests of others is not solely in situations that demand sustained effort and attention or demand that the individual sit still.

Depressive and bipolar disorders

Depressive and bipolar disorders often involve negative affect and irritability. As a result, a diagnosis of oppositional defiant disorder should not be made if the symptoms occur exclusively during the course of a mood disorder.

Disruptive mood dysregulation disorder

Oppositional defiant disorder shares with disruptive mood dysregulation disorder the symptoms of chronic negative mood and temper outbursts. However, the severity, frequency, and chronicity of temper outbursts are more severe in individuals with disruptive mood dysregulation disorder than in those with oppositional defiant disorder. Thus, only a minority of children and adolescents whose symptoms meet criteria for oppositional defiant disorder would also be diagnosed with disruptive mood dysregulation disorder. When the mood disturbance is severe enough to meet criteria for disruptive mood dysregulation disorder, a diagnosis of oppositional defiant disorder is not given, even if all criteria for oppositional defiant disorder are met.

Intermittent explosive disorder

Intermittent explosive disorder also involves high rates of anger. However, individuals with this disorder show serious aggression toward others that is not part of the definition of oppositional defiant disorder.

Intellectual disability (intellectual developmental disorder)

In individuals with intellectual disability, a diagnosis of oppositional defiant disorder is given only if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable mental age and with comparable severity of intellectual disability.

Language disorder

Oppositional defiant disorder must also be distinguished from a failure to follow directions that is the result of impaired language comprehension (e.g., hearing loss).

Social anxiety disorder (social phobia)

Oppositional defiant disorder must also be distinguished from defiance due to fear of negative evaluation associated with social anxiety disorder.

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