Intermittent Explosive Disorder (312.34)

This is a short video by Dr. Gary Solomon explaining what Intermittent Expolsive Disorder is and the symptoms that go along with the disorder.

DSM-IV-TR criteria

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 accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer’s disease)

Associated features

• Some individuals see their impulses as stressful and destructive before, during and after they react to these impulses. These reactions can cause problems socially in their relationships, school, and/or jobs. Individuals with Intermittent Explosive Disorder can sometimes suppress their anger, to an extent, and react in a less destructive manner. Individuals with narcissistic, obsessive, paranoid, or schizoid traits may be especially prone to having explosive outbursts of anger when under increased stress. Some individuals may also report that their aggressive episodes are often preceded or accompanied by symptoms such as tingling, tremor, palpitations, chest tightness, head pressure, or hearing an echo. Individuals may describe their aggressive impulses as extremely distressing. The disorder may result in job loss, school suspension, divorce, difficulties with interpersonal relationships or other impairment in social or occupational spheres, accidents, hospitalization, financial problems, incarcerations, or other legal problems.
• Signs of generalized impulsivity or aggressiveness may be present between explosive episodes. Individuals with Intermittent Explosive Disorder may report problems with chronic anger and frequent “sub threshold” episodes, in which they experience aggressive impulses but either manage to resist acting on them or engage in less destructive aggressive behaviors.

Child vs. adult presentation

• In children, they may react with a temper, hyperactivity, or destructive actions such as tearing up objects, setting objects on fire, or taking from others. There is no exact age of when Intermittent Explosive Disorder begins, however it is believed to occur from childhood to late teens or twenties.
• Intermittent explosive behavior or episodic aggressive outbursts often begin in childhood, adolescence or early adulthood and follow a chronic course. In a study of 27 patients who were diagnosed with IED, 75% of those reported that their explosive behavior began in adolescence, with a mean age of onset of 14 years old, and a mean duration of 20 years old (Olvera 2002).

Gender and cultural differences in presentation

The episodic violent behavior is more frequent in men than women. Amok is uncontrolled, severe violent behavior where a person would declare it was amnesia. This is known to be seen more in the southeastern area of Asia. But, has also been seen in Canada and the United States. However, Amok does not occur frequently, but in a single episode.

Epidemiology

Very little is known about Intermittent Explosive Disorder; it is seen as a very 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 disorder—particularly personality disorders, substance abuse (especially alcohol abuse) disorders, and neurological disorders.

Etiology

• Some studies suggest that abnormalities of the brain that are responsible for regulating behavioral arousal and inhibition could be the cause. Developmental problems or Neurological symptoms maybe a cause. There may be an imbalance of serotonin or testosterone levels. However, if a physician believes it is due to physiological problems, it may be diagnosed as a General Medical Condition instead. It may also be a cause of exposure in family situations at a young age, or a genetic factor. Also, lower levels of brain glucose (sugar) metabolism in patients who act in “impulsively aggressive” ways.
• Impulsive aggression is thought to be mainly defensive in nature, driven by fear, anger and a cognitive distortion of environmental conditions, with extremely high autonomic arousal (Olvera 2002).
• Neurobiological studies of aggression suggest that numerous neurotransmitters are disrupted. A disruption in the serotonergic system, in particular, low cerebral spinal fluid levels of 5-hydroxyindoleacetic acid, a serotonin metabolite, have been found in IED individuals (Olvera 2002).

Empirically supported treatments

Some treatments are seen in certain medications such as anti-convulsion, anti-anxiety, mood regulators, or anti-depressants. Also, some forms of group therapy such as anger management have been seen as helpful. Some medications include: carbamazepine (an antiseizure medicine), propranolol (a heart medication), and lithium (used to treat Bipolar type two manic-depression disorder).