Intermittent Explosive Disorder
Joe Pereira, LICSW, CAS
While the h edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be out shortly, there has been one diagnosis that has been associated with anger control problems and that has been intermittent explosive disorder (IED).
The criteria for intermittent explosive disorder is as follows:
• Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property;
• Grossly out of proportion to any precipitating psychosocial stressors;
• The aggressive behavior is not better accounted for by another mental disorder and is not due to the direct physiological effects of a substance or general medical condition.
The current edition (DSM-IV) includes intermittent explosive disorder in the category of Impulse Control Disorders, Not Elsewhere Classified. Other disorders in this category include kleptomania, pyromania and pathological gambling.
Some mental health professionals have questioned the validity of intermittent explosive disorder as a separate clinical entity and consider the lack of control of aggressive impulses as a nonspecific symptom that occurs in a wide range of psychiatric and medical disorders. A number of health insurance/managed care companies will not accept it as a diagnosis for reimbursement.
Ron Kessler, PhD at Harvard Medical School and his colleagues published a study a few years ago looking at the prevalence and association of intermittent explosive disorder with other mental health problems. The lifetime prevalence of IED in the population was estimated to be 7.3% and over the past 12 months it was estimated to be 3.9%. They found that IED usually begins in childhood or adolescence and is quite persistent over the course of a diagnosed person’s life.
The study found that IED was significantly comorbid with mood, anxiety and substance use disorders. The authors of the study noted that the association of IED with mood and anxiety problems would suggest that IED may be as much related to mood instability and dysregulation as to problems with impulse control.
The study concluded that while about 60% of individuals with IED obtained treatment for emotional or substance abuse problems at some time in their life. However, only about 29% ever received treatment for their anger.
Dr. Susan McElroy at the University of Cincinnati School of Medicine looked at 27 subjects diagnosed with IED. The explosive behavior typically began in adolescence. The impulses were consistently described as a model of “defensive aggression”- that is, the need to attack, strike out or defend oneself. Subjects also described an “adrenaline rush,” “seeing red,” “letting the beast out,” and the “urge to kill somebody.” Of 24 subjects specifically queried, 21 (88%) experienced tension with the aggressive impulses, 18 (75%) expressed relief with the explosive episodes, and 11 (46%) described pleasurable feelings associated with the explosive episodes. All subjects indicated that the episodes were brief with a mean of 22 minutes and the frequency was about 9 per month.
Maurizio Fava, a psychiatrist at Mass General has observed in a number of patients that he has worked with who have been diagnosed with a Major Depressive Disorder, episodes of anger that he has described as “anger attacks.” These incidents usually occur with a high level of physiological arousal similar to panic attack including sweats, chest tightness, shortness of breath and heart racing. During these attacks, people feel quite out of control and after the attacks are guilty and remorseful about their behavior.
Cognitive-behavioral treatment can be helpful with individuals who are diagnosed with IED. This type of therapy can help people identify situations or triggers which can result in an aggressive response. In addition, this type of treatment can assist individuals to regulate their anger by teaching techniques such as relaxation training, thinking differently about life events (cognitive restructuring) and assertiveness skills training.
Further, certain psychiatric medications have also been found helpful in the treatment of IED. Antidepressants such as Prozac and anticonvulsants such as Tegretol and mood stabilizers such as lithium have been used.
Fava, M. et al (1993). Anger Attacks in Unipolar Depression. Part 1: Clinical Correlates and Response to Fluoxetine Treatment. American Journal of Psychiatry, 150, 1158-1163.
Kessler, R.C. et al (2006). The Prevalence and Corre- lates of DSM-IV Intermittent Explosive Disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry, 63, 669-678.
McElroy, S.L. (1999). Recognition and Treatment of DSM-IV Intermittent Explosive Disorder. Journal of Clinical Psychiatry, 60, 12-16.
FROM THE FILES:
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