Intermittent explosive disorder
|Intermittent explosive disorder|
|Classification and external resources|
Intermittent explosive disorder (IED) is a behavioral disorder characterized by extreme expressions of anger, often to the point of uncontrollable rage, that are disproportionate to the situation at hand. Impulsive aggression is unpremeditated, and is defined by a disproportionate reaction to any provocation, real or perceived. Some individuals have reported affective changes prior to an outburst (e.g., tension, mood changes, energy changes, etc.).
The disorder is currently categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) under the "Disruptive, Impulse-Control, and Conduct Disorders" category. The disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder. Individuals diagnosed with IED report their outbursts as being brief (lasting less than an hour), with a variety of bodily symptoms (sweating, stuttering, chest tightness, twitching, palpitations) reported by a third of one sample. Aggressive acts are frequently reported accompanied by a sensation of relief and in some cases pleasure, but often followed by later remorse.
The DSM-IV criteria for IED include: the occurrence of discrete episodes of failure to resist aggressive impulses that result in violent assault or destruction of property, the degree of aggressiveness expressed during an episode is grossly disproportionate to provocation or precipitating psychosocial stressor, and, as previously stated, diagnosis is made when other mental disorders that may cause violent outbursts (e.g., antisocial personality disorder, attention deficit hyperactivity disorder, borderline personality disorder, oppositional defiant disorder, etc.) have been ruled out. Furthermore, the acts of aggression must not be due to a general medical condition, e.g., a head injury, Alzheimer's disease, etc., or due to substance abuse or medication. Diagnosis is made using a psychiatric interview to affective and behavioral symptoms to the criteria listed in the DSM-IV.
The DSM-IV-TR is very specific in its definition of Intermittent Explosive Disorder which is defined, essentially, by exclusion of other conditions. The diagnosis requires:
- several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
- the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
- the episodic violence cannot be better accounted for by another mental or physical medical condition.
Many psychiatric disorders and some substance use disorders are associated with increased aggression and are frequently comorbid with IED, often making differential diagnosis difﬁcult. Bipolar disorder has been linked to increased agitation and aggressive behavior in some individuals, but for these individuals aggressiveness is limited to manic and/or depressive episodes, whereas individuals with IED experience aggressive behavior even during periods with a neutral or positive mood. Similarly, alcohol and other substance use disorders may exhibit increased aggressiveness, but unless this aggression is experienced outside of periods of acute intoxication and withdrawal, no diagnosis of IED is given. For chronic disorders, such as PTSD, it is important to assess whether the level of aggression met IED criteria prior to the development of another disorder. In antisocial personality disorder, interpersonal aggression is usually instrumental in nature (i.e., motivated by tangible rewards), whereas IED is more of an impulsive, unpremeditated reaction to situational stress.
The Diagnostic and Statistical Manual
In the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-I), a disorder of impulsive aggression was referred to as a passive-aggressive personality type (aggressive type). This construct was characterized by a "persistent reaction to frustration with irritability, temper tantrums and destructive behavior."
In the manual's second edition (DSM-II), the construct evolved into explosive personality. Such individuals were characterized as being "aggressive individuals" who display "intermittently violent behavior" and are "generally excitable, aggressive, and over-responsive to environmental pressures" with "gross outbursts of rage or of verbal or physical aggressiveness different from their usual behavior."
In the third edition (DSM-III), this was for the first time codiﬁed as intermittent explosive disorder and assigned clinical disorder status under Axis I. However, some researchers saw the criteria as poorly operationalized. About 80% of individuals who would now be diagnosed with the disorder would have been excluded.
In the DSM-IV, the criteria were improved but still lacked objective criteria for the intensity, frequency, and nature of aggressive acts to meet criteria for IED. This led some researchers to adopt an alternate criteria set with which to conduct research, known as the IED-IR (Integrated Research). The severity and frequency of aggressive behavior required for the diagnosis was clearly operationalized, the aggressive acts were required to be impulsive in nature, subjective distress was required to precede the explosive outbursts, and the criteria allowed for comorbid diagnoses with borderline personality disorder and antisocial personality disorder. These research criteria became the basis for the DSM-5 diagnosis.
In the current version of the DSM (DSM-5), the disorder appears under the "Disruptive, Impulse-Control, and Conduct Disorders" category. In the DSM-IV, physical aggression was required to meet criteria for the disorder, but this criteria was modified in the DSM-5 to include verbal aggression and nondestructive/noninjurious physical aggression. The listing was also updated to specify frequency criteria. Further, aggressive outbursts are now required to be impulsive in nature, and must cause marked distress, impairment, or negative consequences for the individual. Individuals must be at least 6 years old to receive the diagnosis. The text also clarified the disorder's relationship to other disorders such as ADHD and disruptive mood dysregulation disorder.
Two epidemiological studies of community samples approximated the lifetime prevalence of IED to be 4%-6%, depending on the criteria set used. A Ukrainian study found comparable rates of lifetime IED (4.2%), suggesting that a lifetime prevalence of IED of 4%–6% is not limited to American samples. One-month and 1-year point prevalences of IED in these studies were reported as 2.0% and 2.7%, respectively. Extrapolating to the national level, 16.2 million Americans would have IED during their lifetimes and as many as 10.5 million in any year and 6 million in any month.
Among a clinical population, a 2005 study found the lifetime prevalence of IED to be 6.3%.
Of US subjects with IED, 67.8% had engaged in direct interpersonal aggression, 20.9% in threatened interpersonal aggression, and 11.4% in aggression against objects. Subjects reported engaging in 27.8 high-severity aggressive acts during their worst year, with 2-3 outbursts requiring medical attention. Across the lifespan, the mean value of property damage due to aggressive outbursts was $1603.
Treatment is attempted through both cognitive behavioral therapy and psychotropic medication regimens, though the pharmaceutical options have shown limited success. Therapy aids in helping the patient recognize the impulses in hopes of achieving a level of awareness and control of the outbursts, along with treating the emotional stress that accompanies these episodes. Multiple drug regimens are frequently indicated for IED patients. Cognitive Relaxation and Coping Skills Therapy (CRCST) has shown preliminary success in both group and individual settings compared to waitlist control groups. This therapy consists of 12 sessions, the first three focusing on relaxation training, then cognitive restructuring, then exposure therapy. The final sessions focus on resisting aggressive impulses and other preventative measures.
Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, fluvoxamine, and sertraline appear to alleviate some pathopsychological symptoms; the reasons for such will be explained further in the subsequent section. GABAergic mood stabilizers and anticonvulsive drugs such as gabapentin, lithium, carbamazepine, and divalproex seem to aid in controlling the incidence of outbursts. Anxiolytics help alleviate tension and may help reduce explosive outbursts by increasing the provocative stimulus tolerance threshold, and are especially indicated in patients with comorbid obsessive-compulsive or other anxiety disorders.
Impulsive behavior, and especially impulsive violence predisposition has been correlated to a low brain serotonin turnover rate, indicated by a low concentration of 5-Hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF). This substrate appears to act on the suprachiasmatic nucleus in the hypothalamus, which is the target for serotonergic output from the dorsal and median raphe nuclei playing a role in maintaining the circadian rhythm and regulation of blood sugar. A tendency towards low 5-HIAA may be hereditary. A putative hereditary component to low CSF 5-HIAA and concordantly possibly to impulsive violence has been proposed. Other traits that correlate with IED are low vagal tone and increased insulin secretion. A suggested explanation for IED is a polymorphism of the gene for tryptophan hydroxylase, which produces a serotonin precursor; this genotype is found more commonly in individuals with impulsive behavior.
IED may also be associated with lesions in the prefrontal cortex, with damage to these areas, including the amygdala, increasing the incidence of impulsive and aggressive behavior and the inability to predict the outcomes of an individual's own actions. Lesions in these areas are also associated with improper blood sugar control, leading to decreased brain function in these areas, which are associated with planning and decision making. A national sample in the United States estimated that 16 million Americans may fit the criteria for IED.
- McElroy SL (1999). "Recognition and treatment of DSM-IV intermittent explosive disorder". J Clin Psychiatry. 60 Suppl 15: 12–6. PMID 10418808.
- McElroy SL, Soutullo CA, Beckman DA, Taylor P, Keck PE (April 1998). "DSM-IV intermittent explosive disorder: a report of 27 cases". J Clin Psychiatry 59 (4): 203–10; quiz 211. doi:10.4088/JCP.v59n0411. PMID 9590677.
- Aboujaoude, E., & Koran, L. M. (2010). Impulsive control disorders. Cambridge University Press: Cambridge.
- Felthous et al., 1991
- Coccaro et al., 1998
- Highlights of Changes from DSM-IV-TR to DSM-5 by American Psychiatric Publishing. Retrieved from http://www.ldaofky.org/changes-from-dsm-iv-tr--to-dsm-5.pdf on July 13, 2013.
- Coccaro EF, Schmidt CA, Samuels JF et al. Lifetime and 1-month prevalence rates of intermittent explosive disorder in a community sample. J Clin Psychiatry 65:820–824, 2004.
- Kessler RC, Coccaro EF, Fava M, Jaeger S, Jin R, Walters E (June 2006). "The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication". Arch. Gen. Psychiatry 63 (6): 669–78. doi:10.1001/archpsyc.63.6.669. PMC 1924721. PMID 16754840.
- Bromet EJ, Gluzman SF, Paniotto VI et al. Epidemiology of psychiatric and alcohol disorders in Ukraine: Findings from the Ukraine World Mental Health survey. Soc Psychiatry Psychiatr Epidemiol 40:681–690, 2005.
- Coccaro EF, Posternak MA, Zimmerman M (October 2005). "Prevalence and features of intermittent explosive disorder in a clinical setting". J Clin Psychiatry 66 (10): 1221–7. doi:10.4088/JCP.v66n1003. PMID 16259534.
- Boyd, Mary Ann (2008). Psychiatric nursing: contemporary practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. pp. 820–1. ISBN 0-7817-9169-3.
- Ortega AN, Canino G, Alegria M. Lifetime and 12-month intermittent explosive disorder in Latinos. Am J Orthopsychiatry 78:133–139, 2008.
- McCloskey, M.S., Noblett, K.L., Deffenbacher, J.L, Gollan, J.K., Coccaro, E.F. (2008) Cognitive-Behavioral Therapy for Intermittent Explosive Disorder: A Pilot Randomized Clinical Trial. 76(5), 876-886.
- Goodman, W. K., Ward, H., Kablinger, A., & Murphy, T. (1997). Fluvoxamine in the Treatment of Obsessive-Compulsive Disorder and Related Conditions. J Clin Psychiatry, 58(suppl 5), 32-49.
- Bozikas, V., Bascilla, F., Yulis, P., & Savvidou, I. (2001). Gabapentin for Behavioral Dyscontrol with Mental Retardation. Am J Psychiatry, 158(6), 965.
- Virkkunen M, Goldman D, Nielsen DA, Linnoila M (July 1995). "Low brain serotonin turnover rate (low CSF 5-HIAA) and impulsive violence". J Psychiatry Neurosci 20 (4): 271–5. PMC 1188701. PMID 7544158.
- Best M, Williams JM, Coccaro EF (June 2002). "Evidence for a dysfunctional prefrontal circuit in patients with an impulsive aggressive disorder". Proc. Natl. Acad. Sci. U.S.A. 99 (12): 8448–53. doi:10.1073/pnas.112604099. PMC 123087. PMID 12034876.