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Intermittent Explosive Disorder

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 behaviorif 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.

KEY TERMS

Amok A culture-specific psychiatric syndrome first described among the Malays, in which adolescent or adult males are overcome by a sudden fit of murderous fury provoked by a perceived insult or slight. Some researchers consider amok to be a variant of intermittent explosive disorder.

Cognitive therapy Psychological treatment aimed at changing a person's way of thinking in order to change his or her behavior and emotional state.

Delirium Sudden confusion with a decreased or fluctuating level of consciousness.

Kleptomania An impulse control disorder in which one steals objects that are of little or no value.

Neurotransmitter A chemical messenger that transmits an impulse from one nerve cell to the next.

Pyromania An impulse control disorder characterized by fire setting.

Serotonin A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

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): 82024.

Grant, J. E., and M. N. Potenza. "Impulse Control Disorders: Clinical Characteristics and Pharmacological Management." Annals of Clinical Psychiatry 16 (January-March 2004): 2734.

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): 5763.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 200163007. Web site: <www.aacap.org>.

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

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 208929663. Web site: <www.nimh.nih.gov>.

WEB SITES

Citrome, Leslie L., and Jan Volavka. "Aggression." eMedicine, February 8, 2002. Available online at <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 <www.emedicine.com/med/topic3485.htm> (accessed November 10, 2004).

Janie F. Franz

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Franz, Janie. "Intermittent Explosive Disorder." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

Franz, Janie. "Intermittent Explosive Disorder." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. (July 27, 2016). http://www.encyclopedia.com/doc/1G2-3447200315.html

Franz, Janie. "Intermittent Explosive Disorder." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved July 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3447200315.html

Intermittent Explosive Disorder

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.

The reader should note that 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 and eating disorders, and narcissistic, paranoid, and antisocial personality disorders.

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.

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 currently meet the criteria for IED, with a total of 10 million meeting the lifetime criteria for the disorder.

With regard to sex and age group, 80% of individuals diagnosed with IED in the United States are adolescent and adult 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 disagree 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 anger-prone 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.

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 Dr. 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.

Symptoms

The symptoms of IED are described by the DSM-IV criteria for diagnosing the disorder.

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 screeners 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 himself or others, he may be committed against his will for further treatment. In terms of legal issues, a doctor 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 assaultive inside the hospital, he 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.

Prognosis

The prognosis of IED depends on several factors that include the individual's socioeconomic status, the stability of his or her 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% of the 253 individuals with IED that they studied were upset by the results of their explosive outbursts, only 13% 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 (particularly boys) who may be at risk for IED before they enter adolescence.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., revised. Washington, D.C.: American Psychiatric Association, 2000.

Beck, Aaron T., MD. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins Publishers, 1999.

Beers, Mark H., MD., and Robert Berkow, MD, editors. "Psychiatric Emergencies." Section 15, Chapter 194. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Citrome, Leslie L., MD, MPH, and Jan Volavka, MD. "Aggression." eMedicine. February 8, 2002. http://www.emedicine.com/Med/topic3005.htm.

Coccaro, E. F., C. A. Schmidt, J. F. Samuels, and G. Nestadt. "Lifetime and 1-Month Prevalence Rates of Intermittent Explosive Disorder in a Community Sample." Journal of Clinical Psychiatry 65 (June 2004): 820-824.

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., R. Chalansani, K. N. Chengappa, and M. F. Dieringer. "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.

McElroy, Susan L. "Recognition and Treatment of DSMIV Intermittent Explosive Disorder." Journal of Clinical Psychiatry (1999): 12-16.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. http://www.aacap.org.

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

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. http://www.nimh.nih.gov.

OTHER

Padgitt, Steven T. "Treating Intermittent Explosive Disorder with Neurofeedback" Behavenet.com. May 7, 2001. http://www.behavenet.com/capsules/disorders/explosivedis.htm.

KEY TERMS

Cognitive therapy A form of short-term psychotherapy that focuses on changing people's patterns of emotional reaction by correcting distorted patterns of thinking and perception.

Delirium An acute but temporary disturbance of consciousness marked by confusion, difficulty paying attention, delusions, hallucinations, or restlessness. Delirium may be caused by drug intoxication, high fever related to infection, head trauma, brain tumors, kidney or liver failure, or various metabolic disturbances.

Kleptomania A mental disorder characterized by impulsive stealing.

Neurotransmitter Any of a group of chemicals that transmit nerve impulses across the gap (synapse) between two nerve cells.

Pyromania A mental disorder characterized by setting fires.

Serotonin A neurotransmitter or brain chemical that is responsible for transporting nerve impulses.

Cite this article
Pick a style below, and copy the text for your bibliography.

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Franz, Janie; Frey, Rebecca. "Intermittent Explosive Disorder." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

Franz, Janie; Frey, Rebecca. "Intermittent Explosive Disorder." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. (July 27, 2016). http://www.encyclopedia.com/doc/1G2-3451600893.html

Franz, Janie; Frey, Rebecca. "Intermittent Explosive Disorder." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved July 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600893.html

Intermittent explosive disorder

Intermittent explosive disorder

Definition

Intermittent explosive disorder (IED) is a disorder characterized by impulsive acts of aggression, as contrasted with planned violent or aggressive acts. The aggressive episodes may take the form of "spells" or "attacks," with symptoms beginning minutes to hours before the actual acting-out. The Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (also known as DSM-IV-TR ) is the basic reference work consulted by mental health professionals in determining the diagnosis of a mental disorder. DSM-IV-TR classifies IED under the general heading of "Impulse-Control Disorders Not Elsewhere Classified." Other names for IED include rage attacks, anger attacks, and episodic dyscontrol.

Description

Intermittent explosive disorder was originally described by the eminent French psychiatrist Esquirol as a "partial insanity" related to senseless impulsive acts. Esquirol termed this disorder monomanies instinctives, or instinctual monomanias. These apparently unmotivated acts were thought to result from instinctual or involuntary impulses, or from impulses related to ideological obsessions.

People with intermittent explosive disorder have a problem with controlling their temper. In addition, their violent behavior is out of proportion to the incident or event that triggered the outburst. Impulsive acts of aggression, however, are not unique to intermittent explosive disorder. Impulsive aggression can be present in many psychological and nonpsychological disorders. The diagnosis of intermittent explosive disorder (IED) is essentially a diagnosis of exclusion, which means that it is given only after other disorders have been ruled out as causes of impulsive aggression.

Patients diagnosed with IED usually feel a sense of arousal or tension before an outburst, and relief of tension after the aggressive act. Patients with IED believe that their aggressive behaviors are justified; however, they feel genuinely upset, regretful, remorseful, bewildered or embarrassed by their impulsive and aggressive behavior.

Causes and symptoms

Causes

Recent findings suggest that IED may result from abnormalities in the areas of the brain that regulate behavioral arousal and inhibition. Research indicates that impulsive aggression is related to abnormal brain mechanisms in a system that inhibits motor (muscular movement) activity, called the serotoninergic system. This system is directed by a neurotransmitter called serotonin, which regulates behavioral inhibition (control of behavior). Some studies have correlated IED with abnormalities on both sides of the front portion of the brain. These localized areas in the front of the brain appear to be involved in information processing and controlling movement, both of which are unbalanced in persons diagnosed with IED. Studies using positron emission tomography (PET) scanning have found lower levels of brain glucose (sugar) metabolism in patients who act in impulsively aggressive ways.

Another study based on data from electroencephalograms (EEGs) of 326 children and adolescents treated in a psychiatric clinic found that 46% of the youths who manifested explosive behavior had unusual high-amplitude brain wave forms. The researchers concluded that a significant subgroup of people with IED may be predisposed to explosive behavior by an inborn characteristic of their central nervous system. In sum, there is a substantial amount of convincing evidence that IED has biological causes, at least in some people diagnosed with the disorder.

Other clinicians attribute IED to cognitive distortions. According to cognitive therapists, persons with IED have a set of strongly negative beliefs about other people, often resulting from harsh punishments inflicted by the parents. The child grows up believing that others "have it in for him" and that violence is the best way to restore damaged self-esteem. He or she may also have observed one or both parents, older siblings, or other relatives acting out in explosively violent ways. In short, people who develop IED have learned, usually in their family of origin, to believe that certain acts or attitudes on the part of other people "justify" aggressive attacks on them.

Although gender roles are not a "cause" of IED to the same extent as biological and familial factors, they are regarded by some researchers as helping to explain why most people diagnosed with IED are males. According to this theory, men have greater permission from society to act violently and impulsively than women do. They therefore have less reason to control their aggressive impulses. Women who act explosively, on the other hand, would be considered unfeminine as well as unfriendly or dangerous.

Symptoms

IED is characterized by violent behaviors that are impulsive as well as assaultive. One example involved a man who felt insulted by another customer in a neighborhood bar during a conversation that had lasted for several minutes. Instead of finding out whether the other customer intended his remark to be insulting, or answering the "insult" verbally, the man impulsively punched the other customer in the mouth. Within a few minutes, however, he felt ashamed of his violent act. As this example indicates, the urge to commit the impulsive aggressive act may occur from minutes to hours before the "acting out" and is characterized by the buildup of tension. After the outburst, the IED patient experiences a sense of relief from the tension. While many patients with IED blame someone else for causing their violent outbursts, they also express remorse and guilt for their actions.

Demographics

IED is apparently a rare disorder. Most studies, however, indicate that it occurs more frequently in males. The most common age of onset is the period from late childhood through the early 20s. The onset of the disorder is frequently abrupt, with no warning period. Patients with IED are often diagnosed with at least one other disorderparticularly personality disorders , substance abuse (especially alcohol abuse) disorders, and neurological disorders.

Diagnosis

As mentioned, IED is essentially a diagnosis of exclusion. Patients who are eventually diagnosed with IED may come to the attention of a psychiatrist or other mental health professional by several different routes. Some patients with IED, often adult males who have assaulted their wives and are trying to save their marriages, are aware that their outbursts are not normal and seek treatment to control them. Younger males with IED are more likely to be referred for diagnosis and treatment by school authorities or the juvenile justice system, or brought to the doctor by concerned parents.

A psychiatrist who is evaluating a patient for IED would first take a complete medical and psychiatric history. Depending on the contents of the patient's history, the doctor would give the patient a physical examination to rule out head trauma, epilepsy, and other general medical conditions that may cause violent behavior. If the patient appears to be intoxicated by a drug of abuse or suffering symptoms of withdrawal, the doctor may order a toxicology screen of the patient's blood or urine. Specific substances that are known to be associated with violent outbursts include phencyclidine (PCP or "angel dust"), alcohol, and cocaine. The doctor will also give the patient a mental status examination and a test to screen for neurological damage. If necessary, a neurologist may be consulted and imaging studies performed of the patient's brain.

If the physical findings and laboratory test results are normal, the doctor may evaluate the patient for personality disorders, usually by administering diagnostic questionnaires. The patient may be given a diagnosis of antisocial or borderline personality disorder in addition to a diagnosis of IED.

In some cases the doctor may need to rule out malingering , particularly if the patient has been referred for evaluation by a court order and is trying to evade legal responsibility for his behavior.

Treatments

Some adult patients with IED appear to benefit from cognitive therapy. A team of researchers at the University of Pennsylvania found that cognitive approaches that challenged the patients' negative views of the world and of other people was effective in reducing the intensity as well as the frequency of violent episodes. With regard to gender roles, many of the men reported that they were helped by rethinking "manliness" in terms of self-control rather than as something to be "proved" by hitting someone else or damaging property.

Several medications have been used for treating IED. These include carbamazepine (Tegretol), an antiseizure medication; propranolol (Inderal), a heart medication that controls blood pressure and irregular heart rhythms; and lithium, a drug used to treat bipolar type II manic-depression disorder. The success of treatment with lithium and other mood-stabilizing medications is consistent with findings that patients with IED have a high lifetime rate of bipolar disorder .

Prognosis

Little research has been done on patients who meet DSM-IV-TR criteria for IED, although one study did find that such patients have a high lifetime rate of comorbid (co-occurring) bipolar disorder. In some people, IED decreases in severity or resolves completely as the person grows older. In others, the disorder appears to be chronic.

Prevention

As of 2002, preventive strategies include educating young people in parenting skills, and teaching children skills related to self-control. Recent studies summarized by an article in a professional journal of psychiatry indicate that self-control can be practiced like many other skills, and that people can improve their present level of self-control with appropriate coaching and practice.

See also Gender issues in mental health; Self-control strategies

Resources

BOOKS

Baumeister, Roy F., PhD. Chapter 8, "Crossing the Line: How Evil Starts." In Evil: Inside Human Violence and Cruelty. New York: W. H. Freeman and Company, 1999.

Beck, Aaron T., M.D. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins, 1999.

Tasman, Allan, and others, eds. Psychiatry. 1st edition. Philadelphia: W. B. Saunders Company. 1997: 1249-1258.

PERIODICALS

Bars, Donald R., and others. "Use of Visual Evoked-Potential Studies and EEG Data to Classify Aggressive, Explosive Behavior of Youths." Psychiatric Services 52 (January 2001): 81-86.

McElroy, Susan L. "Recognition and Treatment of DSM-IV Intermittent Explosive Disorder." Journal of Clinical Psychiatry 60 (1999) [suppl. 15]: 12-16.

Strayhorn, Joseph M., Jr. "Self-Control: Theory and Research." Journal of the American Academy of Child and Adolescent Psychiatry 41 (January 2002): 7-16.

Laith Farid Gulli, M.D. Bilal Nasser, M.D.

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Intermittent Explosive Disorder

Intermittent explosive disorder

Uncontrollable episodes of aggression, where the person loses control and assaults others or destroys property.

Persons with this disorder experience episodes of aggressive or violent behavior that result in assault of a person or animal or the destruction of property. These intense episodes occur spontaneously, not in response to provocation or threat, and individuals often express regret as soon as the episode ends. Usually he or she does not exhibit aggressive tendencies between episodes. This disorder can appear at any age, but is more common in adolescence through the 20s, and is more common in males. This disorder is believed to be rare, and reliable statistics on the frequency of occurrence are not available.

See also Impulse control disorders.

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