Intermittent explosive disorder

Definition

Intermittent explosive disorder (IED) is a mental disturbance that is characterized by specific episodes of violent and aggressive behavior that may involve harm to others or destruction of property. IED is discussed in the Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV) under the heading of "Impulse-Control Disorders Not Elsewhere Classified." As such, it is grouped together with kleptomania, pyromania, and pathological gambling.

A person must meet certain specific criteria to be diagnosed with IED:

• There must be several separate episodes of failure to restrain aggressive impulses that result in serious assaults against others or property destruction.
• The degree of aggression expressed must be out of proportion to any provocation or other stressor prior to the incidents.
• The behavior cannot be accounted for by another mental disorder, substance abuse, medication side effects, or such general medical conditions as epilepsy or head injuries.

Description

People diagnosed with IED sometimes describe strong impulses to act aggressively prior to the specific incidents reported to the doctor and/or the police. They may experience racing thoughts or a heightened energy level during the aggressive episode, with fatigue and depression developing shortly afterward. Some report various physical sensations, including tightness in the chest, tingling sensations, tremor, hearing echoes, or a feeling of pressure inside the head.

Many people diagnosed with IED appear to have general problems with anger or other impulsive behaviors between explosive episodes. Some are able to control aggressive impulses without acting on them while others act out in less destructive ways, such as screaming at someone rather than attacking them physically.

DSM-IV 's classification of IED is not universally accepted. Many psychiatrists do not place intermittent explosive disorder into a separate clinical category but consider it a symptom of other psychiatric and mental disorders. In many cases individuals diagnosed with IED do in fact have a dual psychiatric diagnosis. IED is frequently associated with mood and anxiety disorders; substance abuse; eating disorders; and narcissistic, paranoid, and antisocial personality disorders .

One culturally specific psychiatric syndrome resembling IED is amok, which was first reported in Malaysia. As the English phrase "running amok" implies, the syndrome is characterized by sudden outbursts of indiscriminate aggression or murderous rage that are completely unprovoked or that are triggered by trivial slights.

Demographics

Although the editors of DSM-IV stated in 2000 that IED "is apparently rare," a group of researchers in Chicago reported in 2004 that it is more common than previously thought. They estimate that 1.4 million persons in the United States meet the criteria for IED, with a total of 10 million meeting the lifetime criteria for the disorder.

The symptoms of IED can appear at any time from late childhood through the early 20s, although the disorder is not usually diagnosed in children. The onset may be abrupt, without any warning in the form of a period of gradual change in the child or adolescent's behavior. IED appears to be more common in people from families with a history of mood disorders or substance abuse. The severity of the disorder appears to peak in people in their thirties and to decline rapidly in people over 50.

With regard to gender, 80 percent of individuals diagnosed with IED in the United States are adolescent and adult males; amok is a syndrome that almost always involves males. Women do experience IED, however, and have reported it as part of premenstrual syndrome (PMS).

Causes and symptoms

Causes

As with other impulse-control disorders, the cause of IED has not been determined. As of 2004, researchers disagreed as to whether it is learned behavior, the result of biochemical or neurological abnormalities, or a combination of factors. Some scientists have reported abnormally low levels of serotonin, a neurotransmitter that affects mood, in the cerebrospinal fluid of some angerprone persons, but the relationship of this finding to IED is not clear. Similarly, some individuals diagnosed with IED have a medical history that includes migraine headaches, seizures, attention-deficit hyperactivity disorder, or developmental problems of various types, but it is not clear that these cause IED, as most persons with migraines, learning problems, or other neurological disorders do not develop IED.

Symptoms

Some psychiatrists who take a cognitive approach to mental disorders believe that IED results from rigid beliefs and a tendency to misinterpret other people's behavior in accordance with these beliefs. According to Aaron Beck, a pioneer in the application of cognitive therapy to violence-prone individuals, most people diagnosed with IED believe that other people are basically hostile and untrustworthy, that physical force is the only way to obtain respect from others, and that life in general is a battlefield. Beck also identifies certain characteristic errors in thinking that go along with these beliefs:

• Personalizing: The person interprets others' behavior as directed specifically against him.
• Selective perception: The person notices only those features of situations or interactions that fit his negative view of the world rather than taking in all available information.
• Misinterpreting the motives of others: The person tends to see neutral or even friendly behavior as either malicious or manipulative.
• Denial: The person blames others for provoking his violence while denying or minimizing his own role in the fight or other outburst.

When to call the doctor

Parents should seek help for any older child or adolescent who has had more than one episode of irrationally angry or destructive behavior—if possible before the individual causes serious injury to others, has his education cut short, or gets into trouble with the law.

Diagnosis

The diagnosis of IED is basically a diagnosis of exclusion, which means that the doctor will eliminate such other possibilities as neurological disorders, mood or substance abuse disorders, anxiety syndromes, and personality disorders before deciding that the patient meets the DSM-IV criteria for IED. In addition to taking a history and performing a physical examination to rule out general medical conditions, the doctor may administer one or more psychiatric inventories or screening tests to determine whether the person meets the criteria for other mental disorders.

In some cases the doctor may order imaging studies or refer the person to a neurologist to rule out brain tumors, traumatic injuries of the nervous system, epilepsy, or similar physical conditions.

Treatment

Emergency room treatment

A person brought to a hospital emergency room by family members, police, or other emergency personnel after an explosive episode will be evaluated by a psychiatrist to see whether he can safely be released after any necessary medical treatment. If the patient appears to be a danger to self or others, he or she may be committed for further treatment. In terms of legal issues, a physician is required by law to notify the specific individuals as well as the police if the patient threatens to harm particular persons. In most states, the doctor is also required by law to report suspected abuse of children, the elderly, or other vulnerable family members.

The doctor will perform a thorough medical examination to determine whether the explosive outburst was related to substance abuse, withdrawal from drugs, head trauma, delirium, or other physical conditions. If the patient becomes violent inside the hospital, he or she may be placed in restraints or given a tranquilizer (usually either lorazepam [Ativan] or diazepam [Valium]), most often by injection. In addition to the physical examination, the doctor will obtain as detailed a history as possible from the family members or others who accompanied the patient.

Medications

Medications that have been shown to be beneficial in treating IED in nonemergency situations include lithium, carbamazepine (Tegretol), propranolol (Inderal), and such selective serotonin reuptake inhibitors as fluoxetine (Prozac) and sertraline (Zoloft). Adolescents diagnosed with IED have been reported to respond well to clozapine (Clozaril), a drug normally used to treat schizophrenia and other psychotic disorders.

Psychotherapy

Some persons with IED benefit from cognitive therapy in addition to medications, particularly if they are concerned about the impact of their disorder on their education, employment, or interpersonal relationships. Psychoanalytic approaches are not useful in treating IED.

Alternative treatment

Some patients diagnosed with IED have reported being helped by biofeedback, mindfulness meditation, and various forms of martial arts. Mind/body therapies appear to be helpful in gaining greater self-control, while martial arts workouts help to channel the person's physical energy or muscular tension.

Prognosis

The prognosis of IED depends on several factors that include the individual's socioeconomic status, the stability of the immediate family, the values of the surrounding neighborhood, and his or her motivation to change. One reason why the Chicago researchers think that IED is more common than previously thought is that most people who meet the criteria for the disorder do not seek help for the problems in their lives that result from it. The researchers found that although 88 percent of the 253 individuals with IED whom they studied were upset by the results of their explosive outbursts, only 13 percent had ever asked for treatment in dealing with it.

Prevention

Since the cause(s) of IED are not fully understood as of the early 2000s, preventive strategies should focus on treatment of young children who may be at risk for IED before they enter adolescence .

Parental concerns

An adolescent or young adult diagnosed with IED can cause severe disruption to family life in many different areas, ranging from the economic costs of property damage or accidents to emotional problems in other family members to serious legal penalties. It is important for the person's family to know that they do not have to tolerate violent behavior, destruction of property, harm to pets, or abuse of smaller or weaker family members. Depending on the specific situation and the pattern of previous explosive episodes, family members of adolescents or young adults may decide to leave the immediate situation, call the police or other emergency help, or take out a restraining order.

Another important dimension of IED is the damage done to the person's own life. One reason for seeking treatment for IED is to get help before the person establishes a record of school suspensions, arrests or other legal problems, hospitalizations for injuries sustained in fights or automobile accidents, or repeated firings from jobs. A history of such issues can lead to a self-fulfilling prophecy in which the person with IED continues to have episodes of uncontrolled aggression because of the belief that he or she cannot overcome the past.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders ,4th edition, Text Revision. Washington, DC: American Psychiatric Association, 2000.

"Psychiatric Emergencies." Section 15, Chapter 194 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

PERIODICALS

Coccaro, E. F., et al. "Lifetime and 1-Month Prevalence Rates of Intermittent Explosive Disorder in a Community Sample." Journal of Clinical Psychiatry 65 (June 2004): 820–24.

Grant, J. E., and M. N. Potenza. "Impulse Control Disorders: Clinical Characteristics and Pharmacological Management." Annals of Clinical Psychiatry 16 (January-March 2004): 27–34.

Kant, R., et al. "The Off-Label Use of Clozapine in Adolescents with Bipolar Disorder, Intermittent Explosive Disorder, or Posttraumatic Stress Disorder." Journal of Child and Adolescent Psychopharmacology 14 (Spring 2004): 57–63.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016–3007. Web site: http://www.aacap.org.

American Psychiatric Association. 1400 K Street, NW, Washington, DC 20005. Web site: http://www.psych.org.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892–9663. Web site: http://www.nimh.nih.gov.

WEB SITES

Citrome, Leslie L., and Jan Volavka. "Aggression." eMedicine , February 8, 2002. Available online at http://www.emedicine.com/Med/topic3005.htm (accessed November 10, 2004).

Wilson, William H., and Kathleen A. Trott. "Psychiatric Illness Associated with Criminality." eMedicine , March 5, 2004. Available online at http://www.emedicine.com/med/topic3485.htm (accessed November 10, 2004).

Janie F. Franz