Case Study: Marcus Johnson (DSM-5-TR: Intermittent Explosive Disorder)

Demographics

• Name: Marcus “M.J.” Johnson

• Age: 33

• Gender: Male

• Occupation: Auto mechanic at a local repair shop

• Background: Married with two children (ages 5 and 8); history of childhood physical abuse and early exposure to domestic violence

Clinical Presentation

Course of Symptoms

Marcus presents for mandated anger management therapy following a workplace altercation in which he threw a wrench at a coworker who criticized his work. He reports a long history of “losing it” over small things, including shouting, throwing objects, and occasionally damaging property.

He describes these outbursts as sudden and uncontrollable, often followed by intense shame and exhaustion. Between episodes, Marcus is calm and remorseful, often buying gifts or apologizing profusely to those affected.

His wife reports that similar episodes occur at home—Marcus has punched walls, smashed phones, and once slammed a door hard enough to injure his hand. He denies any pattern of premeditation or instrumental aggression, insisting, “It’s like a switch flips.”

DSM-5-TR Diagnostic Features

Criterion A:

Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:

1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments) or physical aggression toward property, animals, or individuals, occurring twice weekly, on average, for at least 3 months, without physical injury or destruction of property.

   Marcus frequently yells, curses, and throws objects at work and home—averaging multiple outbursts per week.

OR

2. Three behavioral outbursts involving damage/destruction of property and/or physical assault involving injury within a 12-month period.

   Over the past year, Marcus has broken a television, punched a hole in a wall, and physically shoved a coworker.

Criterion B:

The magnitude of aggressiveness expressed during the outbursts is grossly out of proportion to any provocation or stressor.

Marcus acknowledges that his outbursts are “way too much for the situation,” such as screaming for minutes because his child spilled milk.

Criterion C:

Outbursts are not premeditated and are not committed to achieve tangible objectives (e.g., money, power, intimidation).

He reports the behavior “just happens,” and denies using aggression to manipulate or control others.

Criterion D:

Outbursts cause marked distress in the individual or impairment in occupational/interpersonal functioning, or are associated with legal or financial consequences.

Marcus was suspended from work and is facing a domestic disturbance charge from a prior incident. His marriage is strained due to fear and tension at home.

Criterion E:

Chronological age is at least 6 years (or equivalent developmental level).

Marcus meets the age requirement.

Criterion F:

Recurrent aggressive outbursts are not better explained by another mental disorder (e.g., antisocial or borderline personality disorder, ADHD, conduct disorder, bipolar disorder, or substance intoxication).

Substance use screens are negative; no manic or psychotic symptoms are present.

Specifiers (DSM-5-TR Guidance):

• Current Severity: Moderate (frequent verbal and physical aggression, occasional property damage)

• Course: Episodic, with worsening under stress

Psychological and Behavioral Features

• Emotional dysregulation: Sudden, intense anger disproportionate to trigger.

• Cognitive patterns: Belief that others “disrespect” him or “don’t appreciate” his work.

• Physiological arousal: Rapid heart rate, clenched fists, and facial flushing during outbursts.

• Post-episode remorse: Fatigue, guilt, and depressive mood following aggression.

• Family dynamics: Avoidance by spouse and children; home environment characterized by fear and unpredictability.

Differential Diagnosis (DSM-5-TR Guidance)

Functional Impairment

• Occupational: Written up twice for workplace violence; on probation.

• Social: Estranged from several friends and siblings.

• Family: Children fear his temper; spouse has discussed separation.

• Legal: Two prior misdemeanor charges for property damage.

Treatment Considerations (DSM-5-TR Aligned)

• Cognitive-Behavioral Therapy (CBT): Focus on anger awareness, impulse control, and cognitive restructuring.

• Relaxation and Coping Skills Training: Diaphragmatic breathing, mindfulness, and stress inoculation.

• Pharmacotherapy: SSRIs (e.g., fluoxetine) shown to reduce aggression frequency and intensity.

• Anger Management Groups: Peer support and accountability for behavioral change.

• Family Therapy: Psychoeducation to rebuild trust and safety in the home.

Cultural and Psychosocial Context

• Marcus was raised in an environment where aggression was normalized as discipline (“You had to yell or no one listened”).

• As a Black male in a blue-collar environment, he reports feeling societal pressure to appear “tough” and “in control.”

• Financial stress and long work hours exacerbate irritability.

• His wife’s encouragement to seek therapy marks his first engagement with mental health care.