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Intermittent explosive disorder

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Intermittent explosive disorder
Cartoon of Christina Rossetti in a fit of anger, drawn by her brother Dante (1862).
SpecialtyPsychiatry
SymptomsExplosive outbursts of anger and/or violence, often to the point of rage, that are disproportionate to the situation at hand
TreatmentCognitive behavioral therapy
Frequency3%

Intermittent explosive disorder (IED) is a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence, often to the point of rage, that are disproportionate to the situation at hand (e.g., impulsive shouting, screaming or excessive reprimanding triggered by relatively inconsequential events). Impulsive aggression is not premeditated, and is defined by a disproportionate reaction to any provocation, real or perceived. Some individuals have reported affective changes prior to an outburst, such as tension, mood changes, energy changes, etc.[1]

Episodic dyscontrol syndrome (EDS), an older syndrome now synonymous with IED,[2] or sometimes just dyscontrol, is a pattern of abnormal, episodic, and frequently violent and uncontrollable social behavior[3] in the absence of significant provocation.[4]

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.[5] 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.[6] Aggressive acts are frequently reported to be accompanied by a sensation of relief and in some cases pleasure, but often followed by later remorse.

Pathophysiology

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Impulsive behavior, and especially impulsive violence predisposition, have 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.[7]

IED may also be associated with damage or lesions in the prefrontal cortex, with damage to these areas, including the amygdala and hippocampus, increasing the incidences 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.[8] A national sample in the United States estimated that 16 million Americans may fit the criteria for IED.[9]

EDS was associated with limbic system diseases, disorders of the temporal lobe,[10] or abuse of alcohol or other psychoactive substances.[11][12]

Diagnosis

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DSM-5 diagnosis

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The current DSM-5 criteria for Intermittent Explosive Disorder include:[13]

  • Recurrent outbursts that demonstrate an inability to control impulses, including either of the following:
    • Verbal aggression (tantrums, verbal arguments, or fights) or physical aggression that occurs twice in a week-long period for at least three months and does not lead to the destruction of property or physical injury (Criterion A1)
    • Three outbursts that involve injury or destruction within a year-long period (Criterion A2)
  • Aggressive behavior is grossly disproportionate to the magnitude of the psychosocial stressors (Criterion B)
  • The outbursts are not premeditated and serve no premeditated purpose (Criterion C)
  • The outbursts cause distress or impairment of functioning or lead to financial or legal consequences (Criterion D)
  • The individual must be at least six years old (Criterion E)
  • The recurrent outbursts cannot be explained by another mental disorder and are not the result of another medical disorder or substance use (Criterion F)

It is important to note that DSM-5 now includes two separate criteria for types of aggressive outbursts (A1 and A2) which have empirical support:[14]

  • Criterion A1: Episodes of verbal and/or non-damaging, nondestructive, or non-injurious physical assault that occur, on average, twice weekly for three months. These could include temper tantrums, tirades, verbal arguments/fights, or assault without damage. This criterion includes high frequency/low-intensity outbursts.
  • Criterion A2: More severe destructive/assaultive episodes which are more infrequent and occur, on average, three times within a twelve-month period. These could be destroying an object without regard to value or assaulting an animal or individual. This criterion includes high-intensity/low-frequency outbursts.

DSM-IV diagnosis

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The past DSM-IV criteria for IED were similar to the current criteria, however, verbal aggression was not considered as part of the diagnostic criteria. The DSM-IV diagnosis was characterized by the occurrence of discrete episodes of failure to resist aggressive impulses that result in violent assault or destruction of property. Additionally, the degree of aggressiveness expressed during an episode should be grossly disproportionate to provocation or precipitating psychosocial stressor, and, as previously stated, diagnosis is made when certain other mental disorders have been ruled out, e.g., a head injury, Alzheimer's disease, etc., or due to substance use or medication.[5] Diagnosis is made using a psychiatric interview to affective and behavioral symptoms to the criteria listed in the DSM-IV.[citation needed]

The DSM-IV-TR was very specific in its definition of Intermittent Explosive Disorder which was defined, essentially, by the exclusion of other conditions. The diagnosis required:

  1. several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
  2. the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
  3. the episodic violence cannot be better accounted for by another mental or physical medical condition.

EDS was a category in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).[15] EDS may affect children or adults.[16][17][18] Children are often considered to have epilepsy or a mental health problem. The episodes consist of recurrent attacks of uncontrollable rage, usually after minimal provocation, and may last up to an hour. Following an episode, children are frequently exhausted, may sleep and will usually have no recall.[19]

Differential diagnosis

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Many psychiatric disorders and some substance use disorders are associated with increased aggression and are frequently comorbid with IED, often making differential diagnosis difficult. Individuals with IED are, on average, four times more likely to develop depression or anxiety disorders, and three times more likely to develop substance use disorders.[20] 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.[21]

In one clinical study, bipolar and IED disorders co-occurred 60% of the time. Patients report manic-like symptoms occurring just before outbursts and continuing throughout. According to a study, the average onset age of IED was around five years earlier than the onset age of bipolar disorder, indicating a possible correlation between the two.[20]

Similarly, alcoholism 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 before 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.[22]

Treatment

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Although there is no cure, treatment is attempted through cognitive behavioral therapy and psychotropic medication regimens, though the pharmaceutical options have shown limited success.[23] 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.[23] 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.[23]

In France, antipsychotics such as cyamemazine, levomepromazine and loxapine are sometimes used.[citation needed]

Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs, including fluoxetine, fluvoxamine, and sertraline) appear to alleviate some pathopsychological symptoms.[1][24] GABAergic mood stabilizers and anticonvulsive drugs such as gabapentin, lithium, carbamazepine, and divalproex seem to aid in controlling the incidence of outbursts.[1][25][26][27] 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.[25]

Former treatments for EDS

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Treatment for EDS usually involved treating the underlying causative factor(s). This may involve psychotherapy, or medical treatment for diseases.[28]

EDS has been successfully controlled in clinical trials using prescribed medications, including carbamazepine,[29][30] ethosuximide,[31] and propranolol.[32]

There have been few randomised controlled trials of treatment of EDS/IED. Antidepressants and mood-stabilisers including lithium, sodium valproate and carbamazepine have been used in adults, and occasionally in children with oppositional defiant disorder or conduct disorder to reduce aggression. Cognitive behavioural therapy (CBT) is effective in the treatment of anger. A recent trial randomised adults with IED to 12 weeks of individual therapy, group therapy or waiting list (no therapy). Intervention resulted in an improvement in anger and aggression levels, with no difference between group and individual CBT (Cognitive behavioural therapy). Adolescents and young adults may experience educational and social consequences but also mental health problems, including parasuicide, if IED/EDS is undiagnosed in early childhood.[33]

Epidemiology

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Two epidemiological studies of community samples approximated the lifetime prevalence of IED to be 4–6%, depending on the criteria set used.[9][34] 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.[35] One-month and one-year point prevalences of IED in these studies were reported as 2.0%[34] and 2.7%,[9] 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%.[36]

Prevalence appears to be higher in men than in women.[25]

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.[9]

A study in the March 2016 Journal of Clinical Psychiatry suggests a relationship between infection with the parasite Toxoplasma gondii and psychiatric aggression such as IED.[37]

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A diagnosis of EDS has been used as a defense in court for persons accused of committing violent crimes including murder.[38][39][40]

History

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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 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".[citation needed]

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.[41] About 80% of individuals who would now be diagnosed with the disorder would have been excluded.[citation needed]

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.[22] This led some researchers to adopt 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 were 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.[42] 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 the criteria for the disorder, but these criteria were modified in the DSM-5 to include verbal aggression and non-destructive/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 six 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.[43]

See also

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References

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  1. ^ a b c McElroy SL (1999). "Recognition and treatment of DSM-IV intermittent explosive disorder". J Clin Psychiatry. 60 (Suppl 15): 12–6. PMID 10418808.
  2. ^ McTague, A.; Appleton, R. (1 June 2010). "Episodic dyscontrol syndrome". Archives of Disease in Childhood. 95 (10): 841–842. doi:10.1136/adc.2009.171850. PMID 20515972. S2CID 206845461. ProQuest 1828696754.
  3. ^ Elliott FA. (1984) The episodic dyscontrol syndrome and aggression. Neurologic Clinics 2: 113–25.
  4. ^ Maletzky BM. (1973) The episodic dyscontrol syndrome. Disorders of the Nervous System 34: 178–85.
  5. ^ a b 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.
  6. ^ Tamam, L., Eroğlu, M., Paltacı, Ö. (2011). "Intermittent explosive disorder". Current Approaches in Psychiatry, 3(3): 387–425.
  7. ^ 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.
  8. ^ 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. Bibcode:2002PNAS...99.8448B. doi:10.1073/pnas.112604099. PMC 123087. PMID 12034876.
  9. ^ a b c d 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. Archived from the original on 2011-10-10.
  10. ^ Tebartz van Elst, Dr. L.; F. G. Woermann; L. Lemieux; P. J. Thompson; M. R. Trimble (February 2000). "Affective aggression in patients with temporal lobe epilepsy A quantitative MRI study of the amygdala". Brain. 123 (2). Oxford UK: Oxford University Press: 234–243. doi:10.1093/brain/123.2.234. PMID 10648432.
  11. ^ Drake ME, Hietter SA, Pakalnis A. (1992) EEG and evoked potentials in episodic-dyscontrol syndrome. Neuropsychobiology 26: 125–8.
  12. ^ Harbin HT. (1977) Episodic dyscontrol and family dynamics. American Journal of Psychiatry 134: 1113–6.
  13. ^ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  14. ^ Coccaro, EF, Lee, R, & McCloskey, MF (2014). Validity of the new A1 and A2 criteria for DSM-5 intermittent explosive disorder. Comprehensive Psychology, 55(2). doi:10.1016/j.comppsych.2013.09.007.
  15. ^ McTague, A.; Appleton, R. (1 June 2010). "Episodic dyscontrol syndrome". Archives of Disease in Childhood. 95 (10): 841–842. doi:10.1136/adc.2009.171850. PMID 20515972. S2CID 206845461. ProQuest 1828696754.
  16. ^ Nunn K. (1986) The episodic dyscontrol syndrome in childhood. Journal of Child Psychology and Psychiatry 27: 439–46.
  17. ^ Bach-y-Rita G, Lion JR, Climent CE, Ervin FR. (1971) Episodic (1986) dyscontrol: a study of 130 violent patients. American Journal of Psychiatry 127: 49–54.
  18. ^ Elliott FA. (1982) Neurological findings in adult minimal brain dysfunction and the dyscontrol syndrome. Journal of Nervous and Mental Disease 170: 680–7.
  19. ^ McTague, A.; Appleton, R. (1 June 2010). "Episodic dyscontrol syndrome". Archives of Disease in Childhood. 95 (10): 841–842. doi:10.1136/adc.2009.171850. PMID 20515972. S2CID 206845461. ProQuest 1828696754.
  20. ^ a b Coccaro, E.F. (2012). Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. "American Journal of Psychiatry," 169. 577-588.
  21. ^ Coccaro, EF (2000). Intermittent explosive disorder. Current Psychiatry Reports, 2:67-71.
  22. ^ a b Aboujaoude, E., & Koran, L. M. (2010). Impulsive control disorders. Cambridge University Press: Cambridge.
  23. ^ a b c 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.
  24. ^ 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.
  25. ^ a b c Boyd, Mary Ann (2008). Psychiatric nursing: contemporary practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. pp. 820–1. ISBN 978-0-7817-9169-4.
  26. ^ Bozikas, V., Bascilla, F., Yulis, P., & Savvidou, I. (2001). Gabapentin for Behavioral Dyscontrol with Mental Retardation. Am J Psychiatry, 158(6), 965.
  27. ^ Coccaro EF, et al. "A Double-Blind, Randomized, Placebo-Controlled Trial of Fluoxetine in Patients With Intermittent Explosive Disorder," Journal of Clinical Psychiatry (April 21, 2009): Vol. 70, No. 5, pp. 653–62.
  28. ^ McTague, A.; Appleton, R. (1 June 2010). "Episodic dyscontrol syndrome". Archives of Disease in Childhood. 95 (10): 841–842. doi:10.1136/adc.2009.171850. PMID 20515972. S2CID 206845461.
  29. ^ Tunks ER, Dermer SW. (1977) Carbamazepine in the dyscontrol syndrome associated with limbic system dysfunction. Journal of Nervous and Mental Disease 164: 56–63.
  30. ^ Lewin J, Sumners D. (1992) Successful treatment of episodic dyscontrol with carbamazepine. British Journal of Psychiatry 161: 261–2.
  31. ^ Andrulonis PA, Donnelly J, Glueck BC, Stroebel CF, Szarek BL. (1990) Preliminary data on ethosuximide and the episodic dyscontrol syndrome. American Journal of Psychiatry 137: 1455–6.
  32. ^ Grizenko N, Vida S. (1988) Propranolol treatment of episodic dyscontrol and aggressive behaviour in children. Canadian Journal of Psychiatry 33: 776–8.
  33. ^ McTague, A.; Appleton, R. (1 June 2010). "Episodic dyscontrol syndrome". Archives of Disease in Childhood. 95 (10): 841–842. doi:10.1136/adc.2009.171850. PMID 20515972. S2CID 206845461. ProQuest 1828696754.
  34. ^ a b Coccaro EF, Schmidt CA, Samuels JF et al. Lifetime and one-month prevalence rates of intermittent explosive disorder in a community sample. J Clin Psychiatry 65:820–824, 2004.
  35. ^ 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.
  36. ^ 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. Archived from the original on 2012-07-01.
  37. ^ Coccaro EF, Lee R, Groer MW, Can A, Coussons-Read M, Postolache TT (March 2016). "Toxoplasma gondii Infection: Relationship With Aggression in Psychiatric Subjects" Archived 2016-03-24 at the Wayback Machine. J Clin Psychiatry 77(3): 334–341.
  38. ^ Myers WC, Vondruska MA. (1998) Murder, minors, selective serotonin reuptake inhibitors, and the involuntary intoxication defence. Journal of the American Academy of Psychiatry and the Law 26: 487–96.
  39. ^ Simon, Robert I. (1990-12-01). "A Canadian Perspective (p. 392)". Review of Clinical Psychiatry and the Law (Hardback) (Version 2 ed.). Arlington: American Psychiatric Pub, Inc. p. 424. ISBN 0-88048-376-8. The decision in a case concerning episodic dyscontrol syndrome seems to have expanded the definition of "diseases of the mind". In R. v. Butler, the accused had a history of injuries to the head. He was charged with aggravated assault of his wife's infant son. The child had been badly beaten on the head, and the accused, while admitting that he was alone at home with the child, had no memory of beating the child on the head. The medical history of the accused was brought forward at the trial, and a neurologist ventured the opinion that he sufferred from episodic dyscontrol syndrome, entailing an interruption of normal control mechanisms. His other violent acts were symptomatic. In the court decision, it was noted that disease of the mind had both a legal and medical component.
  40. ^ Tiffany, Lawrence P.; Tiffany, Mary (1990-09-11). "5". The Legal Defense of Pathological Intoxication With Related Issues of Temporary and Self-Inflicted Insanity (Hardcover). New York: Quorum Books. pp. 560. ISBN 0-89930-548-2.
  41. ^ Felthous et al., 1991
  42. ^ Coccaro et al., 1998
  43. ^ "Highlights of Changes from DSM-IV-TR to DSM-5" (PDF). American Psychiatric Association. 2013. Retrieved 6 July 2022.
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