Intermittent Explosive Disorder - Turner White

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Psychiatry Board Review Manual Intermittent Explosive Disorder Kelly Blankenship, DO INTRODUCTION Intermittent explosive disorder (IED) was once considered a rare disorder; however, recent studies have indicated that IED is much more prevalent than previously thought. 1 IED is associated with a high degree of social impairment. In a study of 253 individuals in a community sample diagnosed with IED, 81.3% reported psychosocial difficulties, 50% admitted to difficulties within their life due to their behavior, and 62.5% noted significant difficulties with relationships. 2 IED may lessen in intensity as individuals become older. 3 Diagnosis is difficult, in part due to the vagueness of the DSM diagnostic criteria. 4 Further, the paucity of IED studies makes identifying and treating IED a challenge. Despite these limitations, physicians must assess these impulsive and aggressive patients and be aware of available treatment options for these individuals. 5 DIAGNOSTIC AND ASSOCIATED FEATURES IED is characterized by short-lived episodes of impulsive aggression that are substantially out of proportion to the inciting stressor, resulting in destruction of property or serious assaultive acts. 6 IED is currently listed in the DSM-IV under impulse-control disorders not elsewhere classified. 6 Diagnostic criteria and the name of the disorder have changed over time. In DSM-I, IED was referred to as passive-aggressive personality, aggressive type, and in DSM-II, IED was termed explosive personality disorder. It was not until DSM-III that the term IED was used; however, the DSM-III criteria excluded patients with antisocial personality disorder 7 and generalized aggression or impulsivity, 1 and in the DSM-III-R, patients with borderline personality disorder were excluded. The DSM-IV criteria for diagnosing IED no longer excludes patients with impulsivity or generalized aggression 7 but includes the criterion that another mental disorder, substance abuse, or general medical condition must not better account for the aggressive acts (Table 1). 6 Impulsive aggression is not unique to IED and can be seen in multiple psychiatric and medical conditions. Thus, IED Hospital Physician Board Review Manual is a diagnosis of exclusion. 3 Of note, some studies use terms such as “episodic dyscontrol” or “rage attacks” to describe aggression, making it difficult to pinpoint how many patients meet the criteria for IED. 4 In addition, some doubt that IED is an actual diagnosis and believe that impulsive aggression is a symptom that can be experienced in multiple diseases. 8 The aggressive episodes are often described by patients as “spells” or “attacks,” and the symptoms often appear and resolve in minutes to hours. Symptoms have been described as an “adrenaline rush” or “seeing red.” 1 As with other impulse-control disorders, there is often a feeling of release of tension after the episode. Aggression related to IED is often ego-dystonic and patients feel a sense of remorse and regret after the aggressive act. 3 In a study of 27 patients who met current or past DSM-IV criteria for IED, 33% complained of physical autonomic symptoms such as palpitations, tingling, and tremor prior to the episode, and 52% complained of a change in their level of awareness. 8 In a study of 443 violent men, those who met DSM-III criteria for IED (n = 15) felt that an intimate partner would most likely provoke them. Their attacks usually occurred without warning, and all of the men denied wanting the outburst to occur prior to the episode. Men often attempted to console their victim after their rageful outburst. 9 Impulsive aggression often has different motivations. If motivation includes monetary gain, vengeance, selfdefense, social dominance, expressing a political statement, or when it occurs as a part of gang behavior, IED should not be the diagnosis. 3 The impulsive aggression seen in IED is not the same as the willingly performed and thought out aggression often seen in criminal behavior. Thus, when behavior is premeditated, individuals should not be diagnosed with IED. 4 Because DSM-IV exclusion criteria created difficulties in diagnosing IED, integrated research criteria (IED-IR) have been formed. A study that examined the convergent and discriminate validity of the IED-IR criteria found that IED-IR individuals who met DSM-IV diagnostic criteria for IED were no more aggressive or impaired than IED-IR individuals who did not meet these criteria. 4 In another attempt to clarify diagnostic www.turner-white.com
I n t e r m i t t e n t E x p l o s i v e D i s o r d e r criteria for IED, an interview module for IED (IED-M) was studied. The IED-M required a minimum number of aggressive acts (2 times/wk for 1 mo) and the events must be spontaneous, excessive, and have associated anguish. 5 A pilot study was performed to evaluate the validity of the IED-M in detecting IED in children. 10 Olvera et al 10 provided preliminary data that the IED-M is useful for detecting IED in teenagers. EPIDEMIOLOGY As formulated in the DSM-IV-TR, IED is probably a rare disorder 3 ; however, recent data have indicated that this may not be true. In a chart review of 830 patients in 1983, only 1.1% were found to meet DSM-III criteria for IED. 11 In a second report of 433 aggressive participants, 1.8% qualified for a diagnosis of IED by DSM-III standards. 7 A 2005 study of 1300 patients seeking mental health care found that 6.3% met DSM-IV criteria for lifetime IED and 3.1% met criteria for a current diagnosis of IED. 7 A face-to-face household survey of 9282 individuals found a lifetime and 12-month incidence of IED of 7.3% and 3.9%, respectively. 1 Most studies indicate onset of IED in adolescence. McElroy et al 8 found an average age of onset of 14 years, with the disease lasting an average of 20 years. Seventyfour percent of the participants were male. Kessler et al 1 also found the average disease onset of age 14 years as well as an average of 43 attacks over an individual’s life with an average cost of $1359 for damaged objects per lifetime. In the study, injuries related to the disorder occurred 180 times for every 100 lifetime cases. Risk factors included male sex, young age, lower level of education, being married, employment, and having decreased revenue within the home. 1 Another study found that IED showed a linear pattern of occurrence from young to old and lower to higher education. 7 Individuals who completed a college degree or beyond were 2 times less likely to meet criteria for IED than those who had a high school diploma and/or some college. Further, high school graduates were 2 times less likely to meet criteria for IED as those who did not graduate high school. IED was less common in whites as compared with nonwhites. 7 ETIOLOGY AND PATHOPHYSIOLOGY www.turner-white.com Table 1. DSM-IV-TR Diagnostic Criteria for Intermittent Explosive Disorder A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors C. The aggressive episodes are not better accounted for by another mental disorder (eg, antisocial personality disorder, borderline personality disorder, psychotic disorder, manic episode, conduct disorder, attention-deficit/hyperactivity disorder) and are not due to the direct physiologic effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, head trauma, Alzheimer’s disease) Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington (DC): The Association; 2000:667. Copyright 2000, American Psychiatric Association. At one time, theories regarding impulsive aggression included possession by spirits, humeral imbalances, and moral weakness. As psychiatry advanced, so did its theories on impulsive aggression. In the latter part of the 19th century, 2 main theories evolved: (1) impulsive aggression was, at least in part, due to events experienced in youth and (2) impulsive aggression was the result of differences in brain chemistry and makeup. 3 In studies involving rhesus monkeys, researchers found that disrupting early attachment to parental figures was a risk factor for becoming aggressive at improper times. 12 In a human study that measured gender differences in proactive and reactive aggression, proactive aggression was associated with poor parenting in both sexes, and reactive aggression was associated with traumatic experiences at a young age in females. 13 In monkey studies, female monkeys isolated from their mother immediately and other monkeys for the initial 18 months of their life showed deficits in childrearing, being more indifferent and angry toward their offspring. 12 From a social learning perspective, there is an expectation that children learn to parent from interactions with their own parents. In a study designed to examine the continuities in aggressive parenting and behavior in their offspring, persons exposed to aggressive parenting as children were likely to parent aggressively as adults. It was also found that childrearing also had a direct impact on behavior and relationships experienced as young adults and teenagers. 14 Evidence has suggested that IED is familial and individuals with a family history of IED have an elevated risk for the disorder. 15 Decreased levels of serotonin activity, as measured by cerebrospinal fluid (CSF) concentrations of 5-hydroxyindoleacetic acid (5-HIAA), have been observed in studies of both humans and monkeys with Psychiatry Volume 11, Part 5
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