What Externalizing Means in Psychiatry

“Externalizing” is a term used by mental health professionals to describe and diagnose psychiatric disorders featuring problems with self-control of emotions and behaviors. A person with an externalizing disorder directs antisocial, aggressive behavior outward (externally), at others, rather than turning his or her feelings inward (internalizing).

A person diagnosed with any externalizing disorder has problems controlling emotions and impulses and expresses them with antisocial behavior that often violates the rights of others. For example, he or she may confront other people angrily and aggressively, opposing or “taking on” authority figures or striking back against social limits.

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) groups externalizing disorders under the formal heading of “Disruptive, Impulse-Control, and Conduct Disorders.” They include:

Antisocial Personality Disorder. Unlike the other externalizing disorders, this Cluster B personality disorder is mainly discussed in DSM-5 under the heading “Personality Disorders,” where it’s described as “a pattern of disregard for, and violation of, the rights of others” in persons age 18 years or older whose antisocial conduct began before age 15 years.

Criteria for diagnosing this externalizing disorder include combinations of symptoms that involve:

• Disregarding and violating the rights of others: for example, breaking the law, lying, acting irresponsibly, showing a reckless disregard for one’s or others’ safety, showing lack of remorse

Other factors: Onset of this externalizing disorder before age 15 years includes evidence of conduct disorder.

Oppositional Defiant Disorder. Criteria for diagnosing this externalizing disorder include combinations of symptoms that involve:

• Angry/irritable mood: The person often 1) loses his or her temper, 2) is touchy or easily annoyed, 3) is angry and resentful
• Argumentative/defiant behavior: The person often 1) argues with authority figures or, if a child or teenager, with adults; 2) actively defies or refuses to comply with rules or requests from authority figures; 3) deliberately annoys others; 4) blames others for his or her mistakes or misbehavior
• Vindictiveness (spitefulness): The person has shown this behavior at least twice within the past six months

Other factors: The person’s behavior relates to his or her own distress or that of others close to him or her, or it has a negative impact on the person’s ability to function.

Conduct Disorder. Criteria for diagnosing this externalizing disorder include combinations of symptoms that involve:

• Aggressive behavior toward people and animals: for example, bullying, threatening, intimidating, starting physical fights, using deadly weapons, physically abusing people or animals
• Destruction of property: for example, deliberately setting fires or otherwise destroying property
• Lying
• Theft
• Serious violations of normally accepted rules of conduct

Other factors: The person's behavior seriously negatively affects his or her ability to function socially or at work or school. Also, he or she, if age 18 or older, does not meet the diagnostic criteria for antisocial personality disorder.

Pyromania (Fire-Setting). Criteria for diagnosing this externalizing disorder include combinations of symptoms that involve:

• Deliberate fire-setting more than once
• A feeling of tension or arousal before the act
• Fascination with, interest in, curiosity about, or attraction to fire, the items used to set it, and its social consequences
• Feelings of pleasure, relief, or gratification during and after the act and from watching fires
• Lack of an underlying reason for setting fires (such as for money or to conceal a criminal act)

Other factors: The fire-setting is not better explained by a manic episode or a diagnosis of conduct disorder or antisocial personality disorder.

Kleptomania (Stealing). Criteria for diagnosing this externalizing disorder include combinations of symptoms that involve:

• Repeated failure to resist the impulse to steal objects not needed for personal use or for their monetary value
• Feelings of increasing tension right before the theft
• Pleasure, relief, or gratification during the theft

Other factors: The thefts are not committed to express anger or vengeance and are not responses to delusions or hallucinations.

Intermittent Explosive Disorder. Criteria for diagnosing this externalizing disorder include combinations of symptoms in persons age 6 years and older that involve:

• Impulsive, unplanned, and excessive verbal aggression, physical assault, and property damage that are not done to achieve things such as money or power

Other factors: The repeated aggressive outbursts create severe distress or impairment of function in the person committing them, have financial or legal consequences and are not better explained by another psychiatric or medical disorder.

Note: The brief descriptions provided above are intended to give you a quick overview of the diagnostic criteria for disruptive, impulse-control, and conduct disorders (externalizing disorders). They do not include the many levels of detail a mental health professional must consider in making any of these diagnoses. For additional information, ask your doctor.