What Externalizing Means in Psychiatry

Externalizing is a psychological term that describes psychiatric disorders where people have trouble controlling their emotions and behaviors. People with externalizing disorders direct antisocial and aggressive behavior outward (externally) at other people rather than turning their feelings inward (internalizing) on themselves.

A person diagnosed with an externalizing disorder has difficulties controlling emotions and impulses and expresses them in ways that violate the rights of others. For example, they may confront other people angrily and aggressively, opposing or “taking on” authority figures, or striking back against social limits.

This article will cover mental health disorders with externalizing and give examples of externalizing behaviors.

Psychiatric Disorders Featuring Externalizing

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.”

Oppositional Defiant Disorder

This externalizing disorder is characterized by uncooperative, defiant behavior, aggression and hostility, and disrespect of authority. The diagnostic criteria for oppositional defiant disorder include:

• Angry/irritable mood. The person often:
• Is quick to lose their temper
• Is touchy or easily annoyed
• Is angry and resentful
• Argumentative/defiant behavior. The person often:
• Argues with authority figures or, if a child or teenager, with an adult
• Actively defies or refuses to comply with rules or requests from authority figures
• Deliberately annoys others
• Blames others for their mistakes or misbehavior
• Vindictiveness (spitefulness). The person has shown this behavior:
• At least twice within the past six months

In this externalizing disorder, the behavior relates to a person’s distress or that of others close to them and has a negative effect on their ability to function.

Conduct Disorder

Conduct disorder is characterized by behavior that disregards other people and does not follow socially accepted rules for behavior. The criteria for diagnosing conduct include combinations of symptoms that involve:

• Aggressive behavior toward people and animals. For example:
• Bullying, threatening, intimidating, starting physical fights, using deadly weapons, and/or 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

In this externalizing disorder, a person's behavior seriously negatively affects their ability to function socially, including at work or school. Also, if the person is aged 18 or older, the diagnosis is only made if they do not meet the diagnostic criteria for another externalizing disorder called antisocial personality disorder.

Pyromania (Fire-Setting)

This externalizing disorder is characterized by deliberate fire-setting. The criteria for diagnosing pyromania include combinations of symptoms such as:

• Multiple acts of intentional fire-setting
• Tension/arousal before fire-setting
• Fascination with/attraction to fire, items used to set fires, and/or the social consequences of fires
• Pleasure, relief, or gratification during and after the act or from watching a fire burn
• Lack of an underlying reason for setting fires (e.g., for money or to cover up a crime)

In this disorder, the fire-setting is not better explained by a manic episode or a diagnosis of conduct disorder or antisocial personality disorder.

Kleptomania (Stealing)

This externalizing disorder involves having a compulsion to steal. The criteria for diagnosing kleptomania include:

• Repeated failure to resist the urge to steal unneeded objects (not stolen for monetary value)
• Increased tension right before theft
• Pleasure, relief, or gratification during theft

In this disorder, thefts are not committed to express anger or vengeance. The thefts also are not responses to delusions or hallucinations.

Intermittent Explosive Disorder

This externalizing disorder is characterized by sudden episodes of intense anger. The criteria for diagnosing intermittent explosive disorder in children aged 6 years and older include:

• Impulsive, unplanned, and excessive verbal aggression, physical assault, and property damage are not to achieve outcomes like getting money or power.

In this externalizing disorder, repeated aggressive outbursts create severe distress or impairment of a person’s ability to function, have financial or legal consequences, and are not better explained by another psychiatric or medical disorder.

Antisocial Personality Disorder

Unlike other externalizing disorders, antisocial personality disorder is a Cluster B personality disorder that is mainly discussed in DSM-5 under the heading “Personality Disorders.” It’s described as “a pattern of disregard for, and violation of, the rights of others” in persons aged 18 years or older whose behavior demonstrated evidence of conduct disorder before the age of 15 years old. 

The 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 their own or others’ safety
• Lacking remorse

While psychopathy is often associated with antisocial personality disorder, not every person with ASPD would be considered a psychopath.

What Causes Externalizing?

Externalizing disorders are not just caused by one thing. It’s a combination of risk factors like family history (genetics) and someone’s environment (like their home life and experiences at school) that contribute to whether they’ll have one of these disorders and/or show externalizing behaviors.

Externalizing Examples

Here are some examples of externalizing behaviors:

• A child cries and screams after being told they can’t get a toy at the store. When a caregiver tries to pick them up, the child bites their hand.    
•  A student argues with a teacher, becoming hostile and using language that is inappropriate for the classroom.
• A child smashes plates and glasses on the kitchen floor when asked to do the dishes after dinner.
• A student throws a chair across the room when fighting with a classmate.
• A teen sitting in the school gym at a basketball game takes out their vape pen and takes a puff even though there are signs clearly stating No Smoking/Vaping in the facility. When a coach confronts them, the teen starts yelling and kicking the bleachers. After making a scene, they storm out.

Treating Externalizing Disorders

Since externalizing is part of another disorder, the mental health treatment that’s best suited to a person’s condition and their overall needs will be decided by the providers overseeing their care. For children, caregivers and school support may also be involved in treatment planning.

A combination of therapy and medication may be needed to help people with externalizing disorders. For example, some people benefit from using cognitive-behavioral therapy (CBT) to learn to identify and change their aggressive behaviors. It can also be useful for parents and other adults in a child’s life to have therapy and training to learn how to support a child with externalizing behaviors.

Medications are not generally the first-line treatment for most externalizing disorders, and there are no specific medications approved by the FDA to treat specific conditions like antisocial personality disorder or oppositional defiant disorder. However, some medications, like antidepressants and antipsychotics, can be helpful if a person with these disorders also has another mental health condition.

Summary

Externalizing behavior means a person is having trouble controlling their emotions and behaviors. Externalizing behaviors are linked to specific mental health conditions like antisocial personality disorder and oppositional defiant disorder. Since externalizing behaviors can have a major negative effect on a person’s life and endanger them and others, it’s important that they get the support they need. Therapy and sometimes medication may help people with externalizing disorders control their behaviors more effectively.